Finasteride vs Spironolactone for Female Androgenetic Alopecia: How do side effects compare?

Comparison of Side Effects of Finasteride and Spironolactone For Women

Androgenetic alopecia (AGA), also called female pattern hair loss, is common among women. By age 50, about 40 % of women will have AGA. Treatments include minoxidil, anti androgens, oral contraceptives, laser, PRP, hair transplantation, as well as others. Minoxidil remains the only formally FDA approved treatment.

There are no FDA approved anti androgens for treating female AGA although many are used off label in treating this type of hair loss.  The evidence would suggest that anti-androgens are potentially the most consistently effective treatments. The antiandrogens finasteride and spironolactone are among the most commonly prescribed antiandrogens for treating female AGA. Dutasteride, bicalutamide, flutamide and cyproterone acetate are less commonly prescribed.

Finasteride vs Spironolactone: What are the side effects and how to they compare?

This article will focus on the side effects of spironolactone and finasteride. It is important for both prescribers as well as users of these medications to understand the risks and benefits of these medications before committing to use. The use of antiandrogens is lifelong when treating AGA. These medications can be helpful for treating AGA but are not appropriate for every female patent with AGA. The risks and benefits must be carefully reviewed. All anti androgens are contraindicated during pregnancy and also by any female patient who may become pregnant or is trying to conceive. Antiandrogens have the potential to cause serious harm to a developing fetus.

There have been studies of both finasteride in treating AGA and spironolactone in treating AGA. For Spironolactone, the vast majority of our understanding of side effects comes from understanding the side effects that this medication causes in women who use the medication for acne and hirsutism. There have been no good side by side comparative studies of finasteride and spironolactone in treating AGA.

Overall, studies would suggest that finasteride probably has fewer overall side effects which contributes to its discontinuation rate being lower. However, there are many reasons that physicians may choose spironolactone over finasteride, especially in premenopausal women.

1. Overall side effect rates, Discontinuation Rates and Effectiveness

2. Non specific Effects Spironolactone vs Finasteride among Female Users

3. Specific side Effects Spironolactone vs Finasteride among Female Users

4. Side Effects Related to Breast Health

5. Laboratory Changes among Female Finasteride and Spironolactone Users.

6. Dermatological Side Effects among Female Spironolactone and Finasteride Users.

Summary and Conclusion

One must understand the risks and benefits of finasteride and spironolactone if use of these medications is being considered. These medications remain options for female patients with androgenetic alopecia. A careful review of side effects with one’s physician is essential in all individuals considering these medications. There are clearly certain situations where one medication might be preferred over the other. For example, given the effects on blood pressure, the use of finasteride is often preferred in patients with issues with problematic low blood pressure.

Many of the side effects listed above improve over time. Trueb and colleagues showed showed that finateride side effects decrease over time. This incluces side effects such as libido reduction, breast tenderness, or hypertrichosis/hirsutism decrease over time. Probably, there are some adaptative hormonal changes in brain-hormonal axis or in brain perception that lead to these side effects being less and less noticed.

References

Donovan J. Spironolactone in Female AGA

Donovan J. Bicalutamide for Female AGA

Donovan J. Finasteride Use in Women: Yes or No?

Donovan J. Flutamide in Women who Don’t Respond to Spironolactone

Goodfellow A. Oral Spironolactone Improves Acne Vulgaris and Reduces Sebum Excretion.Br J Dermatol 1984 Aug;111(2):209-14.

Helfer EL et al. Side-effects of spironolactone therapy in the hirsute woman.J Clin Endocrinol Metab. 1988 Jan;66(1):208-11. doi: 10.1210/jcem-66-1-208.PMID: 3335604

Hu et al. The Efficacy and Use of Finasteride in Women: A Systematic Review. Int J Dermatol. 2019 Jul;58(7):759-776.

Hughes BR, Cunliffe W. Tolerance of spironolactone. Br J Dermatol. 1988 May;118(5):687-91. doi: 10.1111/j.1365-2133.1988.tb02571.x.PMID: 2969259

Kohler C, Tschumi K, Bodmer C, et al. Effect of finasteride 5mg (Proscar) on acne and alopecia in female patients with 72. normal serum levels of free testosterone. Gynecol Endocrinol. 2007;23:142–145.

Oliveira-Soares R, et al.  5 mg/day for Patterned Hair Loss in Premenopausal Women.Int J Trichology. 2018 Jan-Feb;10(1):48-50. doi: 10.4103/ijt.ijt_73_15. 

Plovanich M et al.. Low Usefulness of Potassium Monitoring Among Healthy Young Women Taking Spironolactone for Acne. JAMA Dermatol. 2015 Sep;151(9):941-4. doi: 10.1001/jamadermatol.2015.34.

Seale LR, Eglini AN, McMichael AJ. Side Effects Related to 5 α-Reductase Inhibitor Treatment of Hair Loss in Women: A Review. J Drugs Dermatol  2016 Apr;15(4):414-9.

Shaw JC, White LE.  Long-term safety of spironolactone in acne: results of an 8-year followup study. J Cutan Med Surg. 2002 Nov-Dec;6(6):541-5. doi: 10.1007/s10227-001-0152-4. Epub 2002 Sep 12.PMID: 12219252

Townsend KA, Marlowe KF. Relative safety and efficacy of finasteride for treatment of hirsutism. Ann Pharmacother. 2004 Jun;38(6):1070-3.

Trüeb RM, Swiss Trichology Study Group. Finasteride treatment of patterned hair loss in normoandrogenic postmenopausal women. Dermatology 2004;209:202-7.  

Yemisci A et al. Effects and side-effects of spironolactone therapy in women with acne. J Eur Acad Dermatol Venereol. 2005 Mar;19(2):163-6. doi: 10.1111/j.1468-3083.2005.01072.x.PMID: 15752283

Can oral minoxidil be used in patients with allergy to topical minoxidil ?

Small study Suggests Oral Minoxidil Can be used in Patients with Topical Minoxidil Contact Allergy

Topical minoxidil is widely used in the treatment of female pattern hair loss. To date, it remains the only formally FDA and Health Canada approved treatment.

Skin Irritation can occur with topical minoxidil and is more common with minoxidil solution than the newer foam product. This is because the solution contains propylene glycol, a well known cause of irritation and sometimes contact allergy. The foam is devoid of propylene glycol. Rarely, patients can be allergic to the minoxidil component too.

Can patients who are allergic to topical minoxidil use oral minoxidil? According to a new study, the answer is yes.

Oral minoxidil is increasing used as an off label treatment for a variety of hair disorders. Doses used for treating hair loss range from 0.25 mg to 2.5 mg (or more) which are much lower doses than than the doses used in the past for treating high blood pressure (40 to 60 mg). . Side effects of oral minoxidil include shedding, hair growth on the face and body, hives, headaches, swelling in the feet/face and others.

See “10 Things You Need to Know about Oral Minoxidil for Hair Loss”

Therianou and colleagues recently reported 9 patients who demonstrated true patch test proven contact allergy to topical minoxidil but were able to tolerate oral minoxidil without any issues. Patients used oral minoxidil at low doses of 0.25 mg twice daily and follow up for these patients range from 7 to 33 months. None of the 9 patients reported side effects and all 9 patients were satisfied with results of their treatment.

Conclusion

The conclusion of this small study is that patients with patients with allergy to topical minoxidil may be able to use oral minoxidil at low doses without side effects. We don’t know if higher doses would cause problem and we don’t yet know the effects of treatments beyond 3 years. Presumably, the risk would be low.

Reference

Therianou et al. How Safe Is Prescribing Oral Minoxidil in Patients Allergic to Topical Minoxidil? Journal of the American Academy of Dermatology . 2020 Apr 11;S0190-9622(20)30567-3.

Bicalutamide for Female Pattern Hair Loss: Should we add it to the list of anti androgens ?

Bicalutamide (Casodex) is pure anti-androgen with Potential Benefit in Treating Female Androgenetic Alopecia

Bicalutamide is a non-steroidal pure anti androgen that was FDA approved for treating prostate cancer at a dose of 50 mg daily back in 1995. Recent studies have investigated its use in treating female androgenetic alopecia.

STUDY 1: Ismail and colleagues, 2020

Dr. Rodney Sinclair’s group from Australia (Ismail and colleagues, 2020) performed a retrospective review of 316 women treated with bicalutamide. The standard starting dose was 10 mg daily although starting doses ranged from 5 mg to 50 mg in the study. The average age of patients was 49 years with a range of 15-85 years. In the study bicalutamide was usually prescribed together with some other medication including oral minoxidil in 308 patients and spironolactone in 172 patients. Six patients received bicalutamide alone (i.e. monotherapy). The most common adverse effect was mild elevation of liver transaminases in 9 (2.85%) patients. This elevation was mild in all cases (less than twice the upper limit of normal) and asymptomatic in all cases as well.. Furthermore, the liver enzyme elevation resolved without needing to adjust the dose in 4 out of 9 patients. In 2 patients, the transaminitis resolved with further dose reduction. Other side effects bicalutamide in the study included peripheral edema in 2.5 % of patients and gastrointestinal complaints in 1.9 %. Use of bicalutamide provided benefit in the treatment of AGA in women.

STUDY 2: Fernandez-Nieto and colleagues, 2020

Dr. Sergio Vano Galvan’s group from Spain (Fernandez-Nieto et al. 2020) recently published their data of 44 women receiving bicalutamide at doses of 25-50 mg daily. The ages of patients in this study were 20-59 with an average age of 34.8 years. The authors chose higher doses than Sinclair’s group for the simple reason that higher doses of bicalutamide are already commonly used in treating hirsutism. Side effects in this particular study included transient elevation in liver enzymes with 5 of 44 (11.4%) patients having a mild increase liver enzymes - all of which self resolved without a need to stop the drug. In addition to elevated liver enzymes, other reported side effects including were shedding, amenorrhea, headaches and endometrial hyperplasia. None of the patients needed to stop treatment. Similar to the Ismail et al study mentioned above, use of bicalutamide in this study also provided benefit in the treatment of AGA in women.

COMMENTS

These are interesting studies and I suspect we’ll be hearing a lot more about bicalutamide in the years to come. I’ve been using it for a few years now and was encouraged to see some good data here with regard to side effect profile and generally good safety. Bicalutamide has fewer side effects than flutamide, another non stereoidal anti androgen (NSAA) and in general the side effects profile is acceptable when compared to the 2 other commonly used antiandrogens we use for treating androgenetic alopecia - spironolactone and finasteride. Further studies are needed to understand how bicalutamide compares to finasteride and spironolactone and what of side effects we might need to counsel our female patients.

Reference

Ismail et al. Safety of oral bicalutamide in female pattern hair loss: a retrospective review of 316 patients. Journal of the American Academy of Dermatology. Available online 19 April 2020

Fernadez-Nieto Et al. BICALUTAMIDE: A POTENTIAL NEW ORAL ANTIANDROGENIC DRUG FOR FEMALE PATTERN HAIR LOSS.J Am Acad Dermatol. 2020 Apr 19:S0190-9622(20)30667-8. doi: 10.1016/j.jaad.2020.04.054. Online ahead of print.

Hair loss in the Frontal Hairline.

Cause of Frontal Hairline Loss

I enjoyed giving a lecture yesterday to our brilliant University of British Columbia dermatology resident physicians. We discussed the common and uncommon scarring and non-scarring hair loss conditions that affect the frontal hairline of males and females.

The Widow's Peak: How does it form?

Formation of the Widow’s Peak

The widow’s peak is a triangular area of hair in the middle of the hairline. It’s common and not associated with bad luck, bad omen or bad anything...of any kind.

The term is probably 200 years old. How did the name even get started? Well, the term probably comes from a type of headdress that a woman (widow) wore after the death of her husband in the 1500’s. The headdress had a triangular peak right in the middle of the frontal hairline. And so the term.

Studies by Dr Bernie Nusbaum suggested that up to 81 % of women have a widow’s peak. This information comes from his study of hairline characteristics of 360 female volunteers performed at an informal hair salon setting. A 2013 study from Spain involved examination of hairline patterns of 103 premenopausal women. 94.17 % had a widow’s peak.

Men have widow’s peaks. Small children (3-5) do not usually have much of a widow’s peak but the widow’s peak starts to be seen in some individuals in the teenage years. The widow’s peak is not actually “created” by the body - it’s due to the body removing hairs around it on either side. What’s left over is the new adult hairline - containing a widow’s peak in some. In case you were not aware, the hairline we get as adults is not the same as the one we get as children. This is normal. 

For some - the new adult hairline has a widow’s peak.

Reference 

Bernard P Nusbaum et al. Naturally Occurring Female Hairline Patterns. Dermatol Surg. 2009 Jun.

C Ceballos et al. Study of Frontal Hairline Patterns in Spanish Caucasian Women. Actas Dermosifiliogr. 2013 May.

Scalp Trichoscopy: Completely Wonderful but Complete with Its Own Set of Limitations !

Can I just buy a USB trichoscope and figure out my own diagnosis ?

Trichoscopy is a wonderful diagnostic tool. Trichoscopy refers to the use of some sort of handheld device for viewing the scalp with higher magnification. These devices are widespread - they range in price from $ 35 for a pretty reasonable USB microscopy to $ 1,500 for a hand held device to $ 15, 000 for a video dermatoscope.

There are quite a few misconceptions that the pubic has about these devices.

1. Will trichoscopy tell me the diagnosis?

That answer is no. One can buy a USB device, plug it in and see beautiful pictures on the screen. But what does it mean? That requires an expert! It takes a few weeks to become reasonably good at trichoscopy and then a few years to become an expert. The USB trichoscope device does not give a print out that reads “you have androgenetic alopecia” or “you have telogen effluvium.”

Consider a useful analogy. If my air conditioner breaks down, I can certainly get out my tool box and open up the back of the air conditioner and see inside. But unless I known what I’m looking for, the process is not that useful and I will not know what’s wrong with the air conditioner (I can assure you based on my experience with doing this exact task).

2. If the trichoscope won't tell me the diagnosis, can’t I just email the doctor the pictures and he can tell me the diagnosis ?

I don’t like really ever answering two “no” answers in a row , but this answer is also no. We’re commonly asked this question. We have many people who ask us if they can just send in photos they have obtained with their own trichscope. These photos are not helpful UNLESS I have the entire story of the patient’s hair loss and have reviewed their blood tests and know absolutely everything about them. Then these trichoscopic images are a major bonus! It’s true that I can be pretty sure what’s going on by their photos - but not 100 % sure. Doesn't one want to be 100- % sure or at least as close to 100 % sure as possible?

The mistake people make is thinking trichoscopy is “everything.” They think to themselves that all I need to do is take pictures of my scalp of find some clinic to take trichoscopy pictures of my scalp and I’ll know what’s going on! That’s wrong, wrong wrong ….and that’s where I see people run into problems time and time again. Trichsocopy is wonderful but it’s only part of the puzzle. As an aside, some people also make the similar mistake of thinking that their blood test results are “everything.” They think to themselves that all I need to do is get to my doctor and get some blood tests and I’ll know what’s going on! That’s also not a correct approach. One needs the entire story and the chance to see the scalp in it’s entirely.

Although I’m sure I sound like a broken record, I’d like to remind the reader that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s story

2) the findings uncovered during the process of the scalp examination (sometimes including trichoscopy, pull test, clinical exam, card test, etc)

3) the results of relevant blood tests. 

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis.

In summary, I can diagnose so many conditions with trichoscopy - but there are so many situations that I can not.

Let’s take a look at some situations where trichsocopy has it’s limitations.

EXAMPLE 1: TRICHOSCOPY IN THE NON SCARRING ALOPECIAS

Trichoscopy is completely wonderful. It helps me tremendously in the diagnosis of many non scarring alopecia. Most cases of androgenetic alopecia can be diagnosed with trichoscopy but not all! In fact, unless one is very experienced with trichscopy, the early cases of AGA are going to be very challenging to diagnose by trichscopy because there is just not enough miniaturization that has developed yet. So, if a patient buys a trichoscope and sees that their is not much miniaturization, can they conclude they don’t have AGA? No.

Most cases of acute alopecia areata can be diagnosed with trichoscopy. This is certainly one area where trichoscopy is very helpful. But in cases of advanced AA and some cases of alopecia areata incognito, all that might be seen is miniaturization of hairs. It can be difficult to render the diagnosis from trichscopy alone. So how do we diagnose it? Listen to the patient’s story!

Telogen effluvium (TE) refers to a type of hair shedding and is one of the more common diagnoses in women. Guess what? Telogen effluvium has NO definitive specific diagnostic trichoscopic signs ! Yikes! it’s true that the presence of many upright regrowing hairs can be a tip off from trichoscopy that the diagnosis of TE might be present - but it’s not specific. If a person thinks they are going to diagnose their TE by buying a trichoscope, they are wrong.

EXAMPLE 2: TRICHOSCOPY IN THE SCARRING ALOPECIAS

Trichoscopy is completely wonderful. It helps me tremendously in the diagnosis of many scarring alopecia. In fact, the use of trichoscopy has massively reduced my need to perform scalp biopsies. That said, one needs to be aware that some cases of early lichen planopilaris can’t be confidently diagnosed with trichoscopy - the scalp looks just like seborrheic dermatitis! Some cases of early folliculitis decalvans look just like regular ordinary folliculitis !

So does trichosopy help in all these subtle and early forms of these diseases? - no ! It gets me thinking but usually a biopsy is needed to confirm these challenging diagnoses.

Let it be heard though - a good majority of scarring alopecia cases can be diagnosed with trichosopy. Just not all!

As for central centrifugal cicatricial alopecia (CCCA), the best way to diagnose this condition is simply to look at the scalp! Trichoscopy can help but there are not a great number of classic trichscopic signs for CCCA.

FINAL SUMMARY

Many patients want to get blood tests because they think that the blood tests will provide the entire answer the diagnosis. Many patients want to buy a trichoscope (USB dermatoscope) because they feel the trichoscope will provide the answers.

We must always remember that the confident diagnosis of hair loss from from use of the diagnostic SET - all comments from the patient’s story, scalp examination,, trichoscopic examination and blood tests go into figuring out the exact cause.

Delivering More Minoxidil to Hair Follicles: What's possible and what possibly helps?

How can I deliver more minoxidil to my hair follicles?

Topical 2 and 5 % Minoxidil are FDA approved and Health Canada approved for treating androgenetic alopecia. The drug does not help everyone but certainly helps a proportion of users. Given the benefits of minoxidil, there is a tremendous interest in understanding how best to delivery the minoxidil down into the scalp so that hair follicles can use it to stimulate their growth.

In this article, we’ll take a look at 5 methods to deliver more minoxidil to follicles as well as the challenges and limitations associated with these methods.

1. Use the same amount and same concentration of minoxidil and use it with the same frequency…. but apply it properly. 

There’s a bit of a learning curve to applying minoxidil and some people just don’t apply it correctly. Minoxidil probably absorbs better when applied after the scalp is washed and is still a bit warm. But clearly this is impractical for everyone as many do not shampoo daily and many who do like to apply minoxidil at night and shampoo the hair clean in the morning.  Despite this, it’s probably more important to remember to apply the minoxidil every day that fuss about when to apply it and how clean the hair is.

Regardless of how it’s applied, the minoxidil needs to get on the skin of the scalp so it can begin its journey into the scalp. Getting minoxidil on the hair shafts does not help. Similarly, if there is a great deal of gunk blocking the scalp surface, it becomes more difficult for minoxidil to penetrate the scalp. Gunk includes excessive amounts of gel, oils and hair fibers.

2. Use the same concentration of minoxidil, but use more of it... or use it more often.

For some patients, using more minoxidil allows more to get into the scalp. This is especially true for males using minoxidil and may be true for some women as well. It’s clear that using 5 % minoxidil twice daily is better when treating male pattern balding than using 5 % minoxidil once daily. For some women - but not all - this may be true too. The downside of using more minoxidil is a greater chance of side effects. The chance of headaches, dizziness, and hair on the face all increase as the amount of minoxidil increases.

3. Expose the hairs to higher concentrations of topical minoxidil

Theoretically, using higher concentrations of minoxidil may help more get into the scalp. Studies that support the ideal minoxidil concentration are few and far between. In fact, one study suggested surprisingly that 5 % minoxidil was more effective than 10 %. Researchers from Egypt set out to compare the efficacy and safety of 5% topical minoxidil with 10% topical minoxidil and placebo in 90 males with balding. Surprisingly, after the 9 months, partipcants in the 5 % minoxidil group had higher vertex and frontal hair counts compared to study participants in the 10 % minoxidil group and the placebo group. Clearly, we still have a lot to learn and a long way to go. Higher concentrations of minoxidil are not necessarily better.

4. Compound the minoxidil with different topical agents or via other drug delivery strategies to allow minoxidil to penetrate the scalp better.

There is a major interest in the hair research community to figure out how best to get minoxidil into the scalp. Different vehicles, use of so called nanoparticles as well as other techniques are the focus of many studies. 

It’s also clear that use of adjuvants like retinoids can help make minoxidil more effective. Before we look at this concept further, it’s important to understand a few concepts. In order for minoxidil to do it’s job, it needs to be converted to minoxidil sulphate. Hair follicles have the machinery to help with this but some people’s hair follicles are not really that good at it. Scientifically, we say that some people’s hair follicles lack high levels of an enzyme known as “sulfotransferase” and so they cannot convert minoxidil into the active form that actually does all the work.  (The public does not yet have minoxidil sulfotransferase testing kits available to them but this technology may be coming at some point in the near future.) For year now, it has been known that mixing retinoids with minoxidil makes minoxidil work better. It has long been thought that retinoids irritate the scalp and somehow by doing so allow minoxidil to get into the scalp. Now, based on interesting work published by Sharma and colleagues in 2019 it’s realized that retinoids upregulate the minoxidil sulfotransferase enzyme and by doing so help generate greater amounts of active minoxidil sulphate in the scalp.

The use of derma rolling may be yet another strategy to get more minoxidil into the scalp. Scalp Micro-needling" (dermrolling) is a technique whereby a controlled injury is created in the scalp. Skin injury (at least in some situations) can stimulate the production of growth factors and inflammatory cytokines that promote skin healing and possibly hair growth. A "dermaroller" is one such device to cause controlled injury. A dermaroller consists of teeth of different lengths that are attached to a wheel. Dermarollers of 0.5 mm, 1 mm, 1.5 mm are common. These are "rolled" back and forth across the skin to create redness. A 2013 study of 100 patients supports benefit of dermarolling. The study set out to determine in patients who use topical minoxidil (Rogaine, etc) could achieve even further benefit by dermarolling. In the study, half the patients received daily minoxidil and the other half of the patients received weekly dermarolling sessions (using a 1.5 mm dermaroller) in addition to minoxidil treatment. Results showed that patients using a dermaroller achieved greater benefits than those using minoxidil alone. Specifically, 82 % of patients receiving dermarolling felt they achieved greater than a 50 % benefit in their hair compared to just 4.5 % receiving minoxidil alone. Physicians rated the improvements similarly. Hair counts (at an up close level) were increased in the dermarolling group compared to the minoxidil alone group (91.4 vs 22.2 respectively). These studies support the potential benefit of dermarolling - especially to increase the efficacy of minoxidil. More studies need to be done to verify or refute these results as well as to determine the optimal parameters for dermarolling. These include comparisons of daily vs weekly vs monthly treatment and comparisons of 0.5 mm needles, 1 mm or 1.5 mm needles. Studies are also needed to determine if any proportion of patient actually worsen with dermarolling.

5. Eat the minoxidil (or eat more).

If someone has androgenetic alopecia but is not able to achieve high enough concentrations of minoxidil deep under the scalp with use of topical minoxidil, switching from topical minoxidil to oral minoxidil could make sense.  As reviewed above, in order for minoxidil to do it’s job, it needs to be converted to minoxidil sulphate. Hair follicles have the machinery to help with this but some people’s hair follicles are not really that good at it. Scientifically, we say that some people’s hair follicles lack high levels of an enzyme known as “sulfotransferase” and so they cannot convert minoxidil into the active form that actually does all the work. When oral minoxidil is ingested, the liver does the job of converting the minoxidil to minoxidil sulphate - bypassing the need for the hair follicle to do this job.

Patients who don’t respond to topical minoxidil may respond to oral minoxdil. Similarly, patients who don’t respond to very low doses (like 0.25 mg to 0.5 mg) may respond to moderate doses (like 1-2-5 mg). Of course, increasing the dose may increase side effects like headaches, swelling, fluid retention, hives and excessive hair growth on the body.

References

Dhurat R, et al. A randomized evaluator blinded study of effect of microneedling in androgenetic alopecia: a pilot study. Int J Trichology. 2013.

Ghonemy S et al. Efficacy and safety of a new 10% topical minoxidil versus 5% topicalminoxidil and placebo in the treatment of male androgenetic alopecia: a trichoscopic evaluation. J Dermatolog Treat. 2019 Oct 21:1-6. doi: 10.1080/09546634.2019.1654070. [Epub ahead of print]

Jeong WY et al. Transdermal delivery of Minoxidil using HA-PLGA nanoparticles for the treatment in alopecia. Biomater Res. 2019 Oct 31;23:16. doi: 10.1186/s40824-019-0164-z. eCollection 2019.

Sharma A et al. Tretinoin enhances minoxidil response in androgenetic alopecia patients by upregulating follicular sulfotransferase enzymes. Dermatol Ther. 2019 May;32(3):e12915. doi: 10.1111/dth.12915. Epub 2019 Apr 23.

Higher Minoxidil Concentrations: Is More Always Better?

10 % Topical Minoxidil vs 5 % Topical Minoxidil: Which is better?

Minoxidil is FDA approved for treating androgenetic alopecia (male pattern balding and female pattern hair loss). It would seem logical to propose that if the drug minoxidil helps in the treatment of males and females with androgenetic alopecia that more minoxidil should help even more.

Researchers from Egypt set out to compare the efficacy and safety of 5% topical minoxidil with 10% topical minoxidil and placebo in 90 males with balding.  The study was a double-blind placebo controlled randomized trial over 36 weeks. The study comprised three treatment groups: 1) study participants receiving 5 % minoxidil 2) study participants receiving 10 % minoxidil and 3) study participants receiving placebo.

Surprisingly, after the 9 months, partipcants in the 5 % minoxidil group had higher vertex and frontal hair counts compared to study participants in the 10 % minoxidil group and the placebo group.

Conclusion

This was a nice study showing us that even after 40 years of studying minoxidil, we still have a lot to learn and a long way to go. Higher concentrations of minoxidil are not necessarily better - although more studies are clearly needed.

Reference

Ghonemy S et al. Efficacy and safety of a new 10% topical minoxidil versus 5% topicalminoxidil and placebo in the treatment of male androgenetic alopecia: a trichoscopic evaluation. J Dermatolog Treat. 2019 Oct 21:1-6. doi: 10.1080/09546634.2019.1654070. [Epub ahead of print]

Is Androgenetic Alopecia (AGA) Caused Only by the Effects of DHT ?

Despite the Myth, Androgenetic Alopecia is Not Simply a Story of DHT

Androgenetic alopecia is a type of hair loss that affects men and women. In males, this condition is also referred to as male balding or male pattern hair loss and eventually affects some 80 to 90 % of males. In females, the condition is referred to as female pattern hair loss or simply hair thinning and affects 40% of women by age 50. The purpose of this article is to deal with some misconceptions, wrong information, errors and myths that many people have about the role of DHT in the balding process. DHT is certainly important - but other factors must be considered too.

The Evolution of the DHT Theory of Male Balding

Some of the earliest observations about the role of hormones in male balding happened in the time of Aristotle back in 300 BC. Aristotle showed that castrated males (eunuchs) did not develop balding. JB Hamilton in 1942 did additional pioneering work to understand male balding. He showed that male hormones are relevant to the balding process. Specifically, he confirmed observations by Aristotle and others that males that were castrated before puberty did not go on to develop balding. Hamilton took this further and showed that if testosterone was given back to castrated males, the males proceeded to develop male balding. This showed that male balding was an “androgen-dependent” process.

Further key work in understanding male balding was done in the 1970s and ultimately published in the New England Journal of Medicine. These were studies that showed that male pseudohermaphrodite living in the Dominican Republic with a genetic deficiency known as 5 alpha reductase deficiency did not produce dihydrotestosterone (DHT) and did not develop male balding. These findings lead ultimately to the rational development of drugs such as finasteride and dutasteride which block 5 alpha reductase and lower DHT levels.

The Story of Male Pattern Balding has a DHT Chapter but Don't Forget to Read the Others

From 300 BC to the 1990’s, the story of male balding seemed pretty clear. Male hormones, particularly the infamous DHT, seemed to be what male balding was all about. Blocking DHT was what treatments were all about.

Many people incorrectly assume that male balding is just a DHT story. Many people incorrectly assume that this DHT chapter is the only chapter they need to read when trying to understand male balding. While it’s true that DHT has a whole lot to do with male balding - the correct way to state it is “male balding is due in part to the effects DHT on hair follicles that are genetically sensitive to this hormone.”

DHT not the only chapter in the balding story

DHT not the only chapter in the balding story. One only need to consider a few other treatments that are used for balding to very quickly realize that male balding must be much more complex than just a DHT story. Minoxidil (Rogaine), for example, has nothing to do with DHT - and yet it helps some people with male balding. Granted I agree that finasteride and dutasteride are much much better treatments than minoxidil - but if DHT was the only thing we need to think about when it comes to treating male balding then minoxidil would not be expected to have any sort of benefit. Well, it does. Low level laser therapy also has nothing to do with DHT hormone levels - and yet it helps some males with their male balding. Platelet rich plasma (PRP) also has very little to do with DHT- and yet it helps some males with their male balding.

Drug Companies are Investing Large Sums with the Knowledge that Male Balding is Far Far More than A Simply DHT Story.

At least 12 pharmaceutical companies are investing millions upon millions of dollars with the clear understanding that DHT is not the only chapter in the balding storybook. These companies are hoping to the first to market with brand new types of drugs - again drugs that have nothing really to do with DHT. A brief summary of the drugs is below.

If Male AGA is Far More than A Simply DHT Story, Female AGA is Far Far Far More than A DHT Story

If you have now come to realize that male balding is a bit more complex than simply a story about DHT, I’d like to point out that female androgenetic alopecia (i.e. female pattern hair loss) is even more complex. If you think for even a moment that you’re going to apply the same DHT story that you used in males to explain balding to the mechanisms operating in females with androgenetic alopecia, you’re going to come up short in terms of your ability to explain hair thinning in women.

Androgenetic alopecia in females is a far more complex story - and we still don’t know all of the mechanisms that govern how hairs thin in women. Of course, there is some aspects of the DHT story that relevant to female thinning. But finasteride and spironolactone and anti-androgens are far less consistently helpful in females than in males. Other treatments such as minoxidil and laser may be far more helpful in some women than in males. In other words, there are likely several different mechanisms that are contributory to androgenetic alopecia in females besides simply a DHT story. As further information for reflection to readers who still doubt this information, one must consider that some women with a genetic condition that completely makes them insensitive to the effects of androgens (called androgen insensitivity syndrome) can still develop androgenetic alopecia. Even women with low testosterone and low DHT levels can develop androgenetic alopecia. There are even some androgen deficient women who do not develop any balding whatsoever when you give them back supplemental androgens through various means of testosterone replacement therapy.

Conclusion

Is androgenetic alopecia simply due to the sensitivity of hair follicles to DHT? Well, it’s a good story, but it’s only part of the story. The DHT chapter is an important chapter to read in the story of male balding and female thinning, but be sure to read the remaining chapters of the story book. The DHT story is not the only story - and many pharmaceutical companies are banking on this concept.

Take Two Asprins and Call Me in the Morning (... to Discuss your Minoxidil)

Aspirin Potentially Reduces the Effectiveness of Minoxidil

Aspirin (acetylsalicylic acid) has always fascinated me. And it continues to fascinate people and researchers around the world. Apparently, some 58 billion doses of aspirin are taken every year. Researchers published over 1,000 scientific articles pertaining to aspirin last year alone. This just adds a bit more to the 23,000 studies that are already published in the scientific journals of the world.

We all know about aspirin. We take if for headaches. Some take it for preventing heart disease. Some take it for preventing strokes. Research now shows convincingly that taking an aspirin if you’ve had a heart attack can reduce your risk of having a second one. In addition, patients who take an aspirin after experiencing a mini-stroke (i.e. transient ischemic attack) have a reduced risk of having a stroke and a reduced risk of dying. Researchers are now trying to figure out how it can be used to prevent cancer and some dementias. This list of potential uses for aspirin is increasing - which means we could someday actually rise above the 58 billion doses yearly.

Aspirin has many effects in body and one is to inhibit an enzyme known as cyclooxygenase. By doing so, certain inflammatory pathways get shut down and the release of certain prostaglandins is inhibited in tissues.

Aspirin and Minoxidil: New Study Suggests Aspirin May Reduce Minoxidil Effectiveness

A new suggests that minoxidil could potentially reduce the effectiveness of minoxidil. To understand this further, it’s important to appreciate that minoxidil gets converted in the skin to minoxidil sulfate and it’s the minoxidil sulfate that actually does all the work for promote hair growth. The conversion of minoxidil to minoxidil sulfate occurs from enzymes known as sulfotransferases which are found the outer root sheath of hair follicles.

In the liver, it had been appreciated that derivatives of aspirin could inhibit sulfotransferase activity. In a new study, researchers found evidence that aspirin could inhibit sulfotransferase activity in hair follicles too. Using a kit that helps predict whether people respond to minoxidil or not, the researchers found that 14 days of continuous aspirin exposure reduced the number of minoxidil responders in half. Prior to aspirin use, 50 % of subjects in the study were predicted to respond to minoxidil treatment. After using aspirin, this was reduced to 27 %.

Conclusion

This is not definitive proof of aspirin’s ability to reduce the effectiveness of minoxidil, but it is certainly quite interesting and suggestive data. More research is needed to confirm this interesting finding.

Reference

Goren et al. Low-dose daily aspirin reduces topical minoxidil efficacy in androgenetic alopecia patients. Dermatol Ther. 2018 Nov;31(6):e12741. doi: 10.1111/dth.12741. Epub 2018 Oct 8.

The Five Day Modified Hair Wash Test (MWHT)

THE 5 DAY MODIFIED HAIR WASH TEST

The modified hair wash test (MHWT) is an extremely helpful non-invasive test. It is underutilized (or even rarely utilized) by dermatologists mainly because of lack of familiarity, lack of exposure along with the time it takes to interpret the test. It is an extremely powerful technique to differentiate challenging cases of CTE from AGA. The MHWT involves 3 parts: 1) Collecting the Hairs 2) Analyzing the Hairs 3) Interpreting the Results

The patient may perform the first part of the test at home. 

Step 1: Collecting the Hairs

The steps in the MHWT are shown in the diagram below. To perform the MHWT, a patient is instructed to avoid shampooing the hair for 5 days before the date of set test date. On the day of the test, the sink is covered with a gauze. The hair is then shampooed thoroughly and rinsed and rinsed and rinsed again. The hairs trapped in the gauze are collected, dried for 3-4 days and then mailed to the office in the same gauze they were trapped on without moving them off the gauze.

Step 2: Analyzing the Hairs

Step 2 begins when the sample arrives back at the office. Most patients simply mail the gauze and hair back to the office in an envelope. The hairs are then divided according to length into hairs less than 3 cm, hairs 3-5 cm and hairs more than 5 cm. We use the following form to count hairs.

FORM FOR ANALYZING RESULTS OF THE MODIFIED HAIR WASH TEST (MHWT)

Step 3: Interpreting the Results

The number of hairs collected in the MHWT can give a good sense of excessive shedding. Results need to be interpreted by a dermatologist who is familiar with the performance and interpretation of this test.

a) Patients with 10% or more of hairs 3 cm or shorter and who shed fewer than 100 hairs are diagnosed as having androgenetic alopecia (AGA).

b) Patients with fewer than 10% of hairs that were 3 cm or shorter and who shed at least 100 hairs are diagnosed as having chronic telogen effluvium (CTE).

c) Patients with 10% or more of hairs that were 3 cm or shorter and who shed at least 100 hairs are diagnosed as having AGA + CTE

d) Finally patients with fewer than 10% of hairs that were 3 cm or shorter and who shed fewer than 100 hairs are diagnosed as having CTE ‘in remission.’

Prescribing Dutasteride in Males with Balding: Are there any criteria ? Should there be any criteria?

Prescribing Dutasteride in Males

The most effective medical treatments for male balding (at the time of this article being written) are oral finasteride and oral dutasteride. There is no debate about this particular comment. In the present day, as the world grapples with the meaning of “post finasteride syndrome”, dutasteride is increasingly a choice for many physicians where it never might have been a choice before. I see it - and I see more now than I did 2 years ago. I see dutasteride being used and 0.5 mg three times weekly. I see dutasteride used at 2.5 mg once weekly or twice weekly. I see dutasteride being used at 0.5 mg daily. I see dutasteride being used more often - and I too prescribe it more now than I did 10 years ago.

Dutasteride is not formally FDA approved for treating male balding but is still widely used. It’s used “off label” though and certainly has a large number of studies to back up its effectiveness. In some countries, dutasteride does have formal approval.

The public is also increasing asking about dutasteride - and increasingly requesting it. After all, we don’t have a great deal of data implicating dutasteride in the same set of issues that finasteride has. Furthermore, it’s more effective than finasteride. These two points lead many to turn to the drug. Some data suggests side effects like sexual dysfunction are greater with dutasteride than finasteride but certainly not all studies show this. Some in fact, show that side effects of dutasteride are similar to placebo.

We don’t yet fully understand everything behind post finasteride syndrome to even begin to dig into what might be called a post dutasteride syndrome or a general 5 alpha reductase syndrome. More studies are needed.

So, will you prescribe me dutasteride or not?

Many patients come in the clinic wanting to know if I’ll prescribe them dutasteride. Some have been on finasteride and haven’t found that it works - and they want dutasteride. Some don’t want to try finasteride at all - they want dutasteride. Some want both. Some know the dose they want.

it all comes down to understanding the medical evidence and the 20 years of science that comes before. There is not a “yes” or “no” answer to whether I will prescribe dutasteride. I don’t know when a patient walks in the door if these medications are right for them - but I do know before the patient walks out the door if these medications are right for them.

The following are the criteria I use in the clinic for determine if the patient is a candidate for dutasteride. These are my criteria and may not necessary be the guideline principles for everyone.

Top 10 Criteria for Prescribing Dutasteride (Donovan)

1. The patient understands the treatment is life-long if he wishes to maintain active medical treatment of his androgenetic alopecia.

2. The patient is aware of the array of possible side effects that have been reported with use of 5 alpha reductase inhibitors including mood changes, depression, anxiety, sexual dysfunction, enlargement of breast tissue (gynecomastia), penile shrinkage, loss of penile sensation, weight gain, muscle weakness and others. The potential effects of dutasteride on males wishing to father are not completely understood. The patient accepts the risk of these side effects if he chooses to use dutasteride.

3. The patient does not currently have severe depression or currently have severe anxiety that might otherwise present a contraindication to using dutasteride. The patient has not been suicidal in the past or been hospitalized for depression and mental illness within the past 5 years.

4. The patient is aware of reports that some patients have experienced persistent (long lasting) problems even when the drug has been stopped. These are mainly studied in the context of finasteride but should be assumed for now to be relevant to the use of dutasteride. The patient accepts the risk of these side effects if he chooses to use dutasteride.

5. The patient is aware that class action lawsuits have been launched regarding the persistent side effects related to finasteride use.

6. The patient is aware of alternatives for treatment including topical minoxidil, oral minoxidil, topical anti androgens (topical finasteride), low level laser, platelet rich plasma and hair transplantation.

7. The patient has no known issues currently related to male inferility or infertility in a female partner.

8. The patient understands the possibility of dutasteride causing a reduction in sperm count and the rare possibility that these reductions may be permanent or long lasting (even when the drug is stopped). The original dutasteride studies showed that after 6 months of stopping the drug, sperm counts had not returned to normal in all study participants and that the total sperm count in the dutasteride group remained 23% lower than baseline.

   Males who are concerned about the possibility of lower sperm count or fertility issues may consider having baseline semen analysis or baseline FSH, LH, Free T4 and testosterone measurements before starting. These lab tests may provide some guidance about baseline fertility. These issues in point 5 are relevant to males who may wish to father children in the future.

9. The patient does not wish to donate blood and understands that blood donation is not possible for at least 6 months after stopping the drug.

10. The patient understands that dutasteride may affect future prostate cancer screening by affecting the PSA value. These issues need to be discussed at the time of such screen and consideration might be given to baseline screening depending on the age of the patient when starting dutasteride.

Conclusion

I can’t say if a patient is a candidate for starting dutasteride when they walk in the office but after 20-30 minutes I can determine if they are likely to be a good candidate for the drug or not. The answers to the questions and issues above help guide the decision making that goes into figuring out if a patient is a candidate for dutasteride or not. It’s not something that can be ascertained in a matter of a few minutes.

References

Meeker JD, Godfrey-Bailey L, Hauser R. Relationships between serum hormone levels and semen quality among men from an infertility clinic. J Androl 2007;28:397–406.

Combining Oral Minoxidil and Oral Spironolactone for FPHL

New Potential Options for Female Pattern Hair Loss

Female Pattern Hair Loss (FPHL), also known as female hair thinning or female androgenetic alopecia is a common type of hair loss that affects about one-third of women. Most women affected by the condition start with slightly increased hair shedding.  Over time, the patient notices decreased hair density and a more see through appearance to the scalp.

Topical Minoxidil remains the only formally FDA and Health Canada approved treatment for FPHL. Application of minoxidil does have it's own unique set of challenges. Many patients give up after a period of time. Other options including oral anti-androgens, laser, PRP and hair transplantation (for some women).

Oral minoxidil has been around for many decades and was originally used as a blood pressure medication. It is known to increase hair growth on the body as a side effects. Recently there has been increased interest worldwide in understand the potential benefits of using low dose oral minoxidil to treat hair loss. Rather than using the 10-40 mg doses that were once used to treat blood pressure, low dose oral minoxidil for hair loss involves doses ranging from 0.25 mg to 2.5 mg. 

Rod Sinclair from Australia set out to study the potential benefits of using oral minoxidil and oral spironolactone together. The dose of minoxidil prescribed was 0.25 mg and the dose of spironolactone used was 25 mg.

100 women were included in this study. The mean age was 48.44 years and the mean duration of diagnosis was 6.5 years. Overall the drug combination reduced shedding and reduced hair loss. There was a slight reduction in mean blood pressure of 4.52 mmHg systolic and 6.48 mgHg diastolic.  8 % of patients in the study have side effects but they were deemed mild.   Only 2 of the 100 patients overall discontinued treatment and these were patients with hives (urticaria).

Conclusion

This is an interesting study. It has long been known that the combination of topical minoxidil and oral spirionlactone (at higher does) are beneficial to FPHL. In fact, it was Dr Sinclair who showed this many years ago as well. This study is interesting because of the safety and limited side effects that were observed. Only 2 % of patients dropped out of the study. In another study by Dr. Sinclair (of chronic telogen effluvium) which also involved study of oral minoxidil, there were no drop outs. Together, these studies speak to a relatively good safety profile of oral minoxidil. 

We have been using oral minoxidil in clinic for some time. I was first inspired to consider it by presentation by Dr SInclair a few years back. (Nobody in the world has more experience with oral minoxidil for hair loss than Dr. Sinclair). The most common side effects is the increased hair on the face (especially upper lip) and body that some patients get. Dizziness, headaches, hives, ankle swelling are among the other side effects. The most common side effect in practice is increased hair on the upper lip in 25- 35 % of women. Other less common side effects are typically headaches, ankle swelling, hives. Surprisingly, shedding does not tend to be very common when starting. The ease of taking oral minoxidil vs topical minoxidil does make it a important option for further study. 

More studies of oral minoxidil are needed but studied to date are promising.

See Article “The Top 10 Things You need to Know About Oral Minoxidil” 

REFERENCE

Female pattern hair loss: a pilot study investigating combination therapy with low-dose oral minoxidil and spironolactone. Sinclair RD. Int J Dermatol. 2018.

Saw Palmetto: How Does it Compare?

How Does it Compare?

For men with balding (androgenetic alopecia) there is no argument that oral antiandrogens are the most effective non-surgical treatment. However the potential side effects of antiandrogens means that for some patients (and physicians) other options can be considered. These options include topical and oral minoxidil, topical finasteride, laser, PRP, topical rosemary, ketoconazole, zinc pyrithione, and others.

Saw palmetto, known medically as sernenoa repens, is frequently added to the list of options. Unfortunately there are very few good studies of the use of saw palmetto in male balding. Rossi and colleagues performed a two year study comparing daily use of 320 mg saw palmetto to 1 mg finasteride in 100 patients with balding. Overall, saw palmetto helped 38% of patients whereas finasteride helped 68% of patients. Finasteride helped both the front and crown/vertex whereas saw palmetto tended to be mainly helpful for the crown.

Conclusion

We still have a long way to go to really understand the benefits of saw palmetto. A well conducted randomized double blind study is needed. However the Rossi study is encouraging that saw palmetto may have some benefits.

Reference

Rossi et al. Comparitive effectiveness of finasteride vs Serenoa repens in male androgenetic alopecia: a two-year study.Randomized controlled trial. Int J Immunopathol Pharmacol. 2012 Oct-Dec.
 

Rosemary Essential Oil: Rosmarinus Officinalis

Rosmarinus Officinalis

Several essential oils have received attention with regard to a potential role in hair growth.

In 2015, Panahi and colleagues published a randomized study of 100 patients - 50 who received 2 % minoxidil and 50 who received rosemary essential oil for a period of 6 months. This study showed that rosemary was fairly similar in effectiveness to 2 % minoxidil. 

Conclusion

This small study was encouraging and supports a potential role for rosemary essential oils in androgenetic alopecia. 

Reference

Panahi et al. Skinmed 2015.

Essential Oils & Hair Loss: A Closer Look at Thyme

A Closer Look at Thyme

Several essential oils have received attention with regard to a potential role in hair growth. These include rosemary, thyme, lavender and cedarwood oil among others.

To date there has been little independent and published studies of the essential oil thyme. It is frequently combined with other essential oils in a mixture and the mixture is then studied together. Treatment with such a mixture is frequently referred to as “aromatherapy.” To date there are few well conducted studies of aromatherapy or essential oils in treating hair loss. However, a particularly well conducted one is a study from 1998 by Dr Hay and colleagues.

The study involved a randomized controlled study of 84 patients with the autoimmune condition alopecia areara. 43 received treatment with aromatherapy consisting of rosemary, thyme, lavendar and cedarwood oil in a carrier oil and 41 received the placebo (carrier oil alone). Interestingly, nineteen (44%) of 43 patients in the active “aromatherapy” group showed improvement in their alopecia areata compared with 6 (15%) of 41 patients in the control group.

To date, this remains one of the best studies looking at the role of essential oils in treating alopecia areata. Whether one particular component played the key role or whether all the essential oils together had a benefit is not known.

Essential oils are relatively safe although may be irritating for some. Surprisingly, the study has not been repeated in the published medical literature since it was introduced to the world 20 years ago. More studies of the role of essential oils in hair loss is needed.
 

Reference

Hay IC et al. Randomized trial of aromatherapy. Successful treatment for alopecia areata.
Randomized controlled trial. Arch Dermatol. 1998.

Smoking and Toxic Metals: Accumulation in Hair Follicles

Accumulation in Hair Follicles

Smoking is a source of exposure to toxic heavy metals - and such exposures have many health implications to many cell types including hair follicles.

Metals have both an essential role in the body but can also be toxic. For example, iton plays a key role in many metabolic functions. Cobalt is the key metal in vitamin B12 molecules. Without certain metals, humans can not survive.

Toxic metals are metals that have the ability to accumulate in the body and affect a variety of normal functions. A variety of metals are studied with regard to effects on the human body. These include mercury, cadmium, lead and silver.

The effect of smoking on how heavy metals accumulate in the body has been studied for many years. Most studies focus on measuring the levels of these toxic metals in hair follicles. Generally speaking the level of these metals in hair follicles provides a surrogate measure of how the metal might be accumulating inside the body. One should not forget that these results also provide us with valuable information about how hair follicles themselves are affected by smoking.

A recent study by Zhu an colleagues in adults showed a positive correlation between nicotine and conitine (a metabolite of nicotine) and levels of mercury, cadmium, lead and silver in hair.

A recent study in 822 children by Li and colleagues showed that second hand smoke was associated with increase levels of cadmium and lead in their hair which correlates with the accumulation of these metals in the body.
 

Conclusion

There is little doubt that smoking is associated with an accumulation of certain toxic metals in both hair follicles as well as the body.
 

Reference

Secondhand smoke is associated with heavy metal concentrations in children. Li L, et al. Eur J Pediatr. 2018.

Association Between Chronic Exposure to Tobacco Smoke and Accumulation of Toxic Metals in Hair Among Pregnant Women.
Zhu Y, et al. Biol Trace Elem Res. 2018.

Minoxidil for Use in the Temples.

Does minoxidil help the temples?

Minoxidil is a topical medication that is FDA approved for treating androgenetic hair loss (male balding) in men. The initial studies that lead to its approval were performed in men with hair loss in the crown (top of the scalp) and this lead to labeling on packaging indicating that it helped the crown. The early studies were not conducted on the front of the scalp and temples and so manufacturers were therefore not permitted to label the product as helping the frontal scalp and temples.

Minoxidil can help temples and frontal hairline

Minoxidil can most certainly help the frontal hairline and temples - especially in younger men and especially in the earliest stages of balding. It may not restore it to the 'original' density. But it certainly can help a proportion of males.  Two studies in the past played a key role to nicely demonstrate that minoxidil helps the frontal hairline. 

STUDY 1:   Hillman and colleagues

IN 2015, Hillman K et al published a study that evaluated the efficacy of twice daily 5% minoxidil foam in the temples of male patients with genetic hair loss. The study was a 24 week study and compared outcomes to placebo treatment and to the vertex region.  Study results indicated that hair counts and hair caliber increased significantly compared to baseline in both the temples and vertex scalp.   Furthermore, patients actually using 5% minoxidil foam rated a significant improvement in scalp coverage for both the front  and top areas.

   

STUDY 2 -  Mirmirani and colleagues

In 2014, Mirmirani et al conducted  a double-blinded, placebo controlled study of minoxidil topical foam 5% (MTF) vs placebo in  16 men ages 18-49 years with androgenetic hair loss. Study participants applied treatment (active drug or placebo) to the scalp twice daily for eight weeks. Again, similar to the previous study, results showed that minoxidil improved frontal and vertex scalp hair growth of AGA patients.

Conclusion

There is no doubt now that minoxidil can help some men with hair loss in the frontal scalp and temples. It does not help everyone, and doesn't bring the hair back to the original density - but it certainly can help. 

 

REFERENCES

Hillman K et al. A Single-Centre, Randomized, Double-Blind, Placebo-Controlled Clinical Trial to Investigate the Efficacy and Safety of Minoxidil Topical Foam in Frontotemporal and Vertex Androgenetic Alopecia in Men. Skin Pharmacol Physiol. 2015;28:236-244.  

Mirmirani et al. Similar Response Patterns to 5%Topical Minoxidil Foam in Frontal and Vertex Scalp of Men with Androgenetic Alopecia: A Microarray Analysis. Br J Dermatol. 2014 Sep 10. 

Using Dutasteride in Male Pattern Balding.

Use of Dutasteride in Previous Finasteride users. 

Currently used 5 alpha reductase inhibitors include finasteride and dutasteride. Finasteride is FDA approved for hair loss at 1 mg. Dutasteride is not formally FDA approved for treating balding. However, the medication can can be used off label. 

Finasateride is an inhibitor of the enzyme 5 alpha reductase type 2  and dutasteride is an inhibitor of both 5 alpha reductease type 1 and type 2. Dutasteride is more potent and leads to greater reductions of dihydrotestosterone (DHT). Studies from 2004 showed that dutasteride lowers serum DHT by up to 90% whereas finasteride lowers it by about 70 %. Side effects are also potentially greater with dutasteride than finasteride.

Options for Using Dutasteride

Patients using finasteride who find that the medication has not given them the growth they hoped for or who feel that their hair loss has progressed slowly over time should speak to their physicians about options. There are several points to discuss with your health care provider. Many individuals who have a “partial” response to finasteride often wonder if they should switch to dutaseteride or add dutasteride to thr finasteride they are already taking.

1. Adding dutasteride on weekends.

Adding a very small dose of dutasteride on the weekends can often be an option for some men.  An Australian study in 2013 reported a male who was initially treated with finasteride for androgenetic alopecia (male balding). Despite good compliance with the medication, the patient noted his hair density was not as good as previous years, and low-dose dutasteride at 0.5 mg once per week was added to the finasteride therapy. Interestingly, this treatment plan resulted in a dramatic increase in his hair density, demonstrating that combined therapy with finasteride and dutasteride can improve hair density in patients already taking finasteride.

2. Switching to dutasteride altogether

Another option that patients may wish to discuss with their physicians is whether to stop finasteride altogether and start dutasteride.  In 2014, Jung and colleagues from South Korea studied 31 men with male balding who took dutasteride after finasteride did not help them. Well over three quarters of these men  (77 %) improved their hair density by making the switch (17 improved slightly, 6 moderately, 1 markedly).

Conclusion

The use of dutasteride is among the treatment options for men with incomplete responses to finasteride. 

Reference:

Jung et al. Effect of dutasteride 0.5 mg/d in men with androgenetic alopecia recalcitrant to finasteride. Int J Dermatol. 2014 Nov;53(11):1351-7

Boyapati A and Sinclair R. Combination therapy with finasteride and low-dose dutasteride in the treatment of androgenetic alopecia. Australasian J Dermatol 2013

Classic studies from the Past: A Look at the Early Dutasteride Studies

Dutasteride vs Finasteride: Suppression of DHT

In the world of hair loss, we often quote numbers and statistics. We frequently throw around information without a good idea of where that information actually came from. An important study is a 2004 study by Dr. Clark and colleagues. It is one of the the classic studies examining how DHT changes with use of finasteride and dutasateride. 

The researchers studied 399 men with prostate enlargement (BPH) and randomized them to once-daily dosing for dutasteride (0.01, 0.05, 0.5, 2.5, or 5.0 mg), or 5 mg finasteride, or placebo for a total of 24 weeks. The percent decrease in DHT was 98% with 5.0 mg dutasteride and 95% with 0.5 mg dutasteride. This was found to be significantly lower than the 71% suppression observed with 5 mg finasteride.  Moreover there was less variability in DHT changes with dutasteride than finasteride. 

Clark et al. Marked suppression of dihydrotestosterone in men with benign prostatic hyperplasia by dutasteride, a dual 5alpha-reductase inhibitor. J Clin Endocrinol Metab. 2004

The other important part of their studies was the increased in DHT that follows stopping the medication. The graph above shows that DHT levels rise much more slowly when dutasteride is stopped than when finasteride is stopped. This is on account of the long half life of dutasteride compared to finasteride (6 hours for finasteride and 4-5 weeks for dutasteride).

Reference

Clark RV, et al. Marked suppression of dihydrotestosterone in men with benign prostatic hyperplasia by dutasteride, a dual 5alpha-reductase inhibitor. Randomized controlled trial. J Clin Endocrinol Metab. 2004.