Should I Start Finasteride for My Androgenetic Alopecia (AGA)?

Is now the right time to start finasteride?

Oral finasteride and topical minoxidil remain the only FDA and Health Canada approved treatments for androgenetic alopecia in men. This form of hair loss is also known as male pattern balding. Other non-surgical treatments can be considered “off-label” as well including laser, PRP, oral minoxidil, topical finasteride, micro needling, oral dutasteride, dutasteride mesotherapy and saw palmetto. Lower doses of finasteride including 0.25 mg daily and 0.5 mg daily or every other day can also be considered. Hair transplants are a good surgical option for many males over 25 for the frontal and mid scalp. The crown can often be transplanted after age 35.

The decision to start or not to start finasteride can be quite involved for many men. A good knowledge of all the treatment options available and the realistic chances of benefits with all the options helps guide the right strategy for each patient.

The treatments available in the world for treating male pattern balding are not all the same in terms of effectiveness or safety or costs or even the ease of doing the treatment. Oral finasteride and oral dutasteride are among the most consistently effective treatments for AGA. However, the chances of side effects and the severity of side effects if they were to occur is greater for oral finasteride than many of the other less effective treatments like laser, PRP and minoxidil. If oral finasteride and oral dutasteride were not more effective than the other treatments, it would not be a discussion point and patients would not face the dilemma was to whether to start these treatments. However, finasteride is more effective and so patients who wish to pursue aggressive treatments need to consider all their options.

Starting Oral Finasteride: Yes or No?

I’m often asked by patients - when is the right time for me to consider oral finasteride ?

In my opinion, the answer may be to start now, or possibly to start in the future or possibly never to start at all.

However, a male should only even start oral finasteride if five conditions are met.

Criteria 1: The individual has a proven (confirmed) diagnosis of androgenetic alopecia.

Finasteride is helpful for treating androgenetic alopecia but finasteride not helpful if other causes of hair loss are actually the reason why the patient is losing hair. If the patent has hairline maturation, telegenic effluvium, scarring alopecia or seborrheic dermatitis as the main reason for the hair loss, finasteride should not be used.

Furthermore, I don’t personally feel finasteride should be started just in case or to prevent AGA in a patient who does not have the condition. Treatment for AGA, whether finasteride or other, should only be considered when their are changes in the scalp that support a diagnosis of AGA.

Criteria 2: The individual does not have any absolute contraindications to this particular medication.

Finasteride is not appropriate for everyone. Males with severe depression may not be good candidates for treatment with finasteride. Furthermore, males with existing sexual dysfunction may not be ideal candidates or may need to stop if sexual dysfunction worsens .Males with existing concerns about gynecomastia (breast enlargement) may have a relative contraindication to starting this drug.

Criteria 3: The individual accepts the potential side effects of this drug.

No male should begin finasteride without understanding all the side effects. Each patient needs to sit down one on one with their doctor and review them. The risks of depression, sexual dysfunction, gynecomastia need to be reviewed. The concept of persistent sexual dysfunction and post finasteride syndrome (PFS) needs to be reviewed. In the end, if a male accepts the small risks associated with use of finasteride, starting the drug may make sense.

Criteria 4: The individual has considered the other treatment options for male balding but feels they are not better for them at this point (topical minoxidil, oral minoxidil, topical finasteride, laser, PRP, hair transplants, SMP and micro needling).

I don’t think any male should start finasteride without knowing something all the treatment options, including how well the work, how much they cost and how safe they are. Every male who starts finasteride should ideally be knowledgeable about other treatments like topical minoxidil/oral minoxidil, PRP, laser, dutasteride, micro needling. In the end, the patient may decide the using finasteride is the right option for them. Of course, many patients will elect to use finasteride in conjunction with other treatments like minoxidil, PRP and laser.

My own opinion is that for many males with early androgenetic alopecia, starting finasteride 1 mg daily is often not the right initial plan for everyone. Consideration should be be given to starting topical finasteride, topical or oral minoxidil or topical finasteride/minoxidil before considering oral finasteride. Now this protocol does not apply to every male and there certainly are some males with more advanced balding who are only really going to benefit from oral finasteride.

But even when we do decide to start finasteride, we really need to consider if 1 mg its the right dose of whether 0.5 mg daily could be a reasonable starting dose. This off label dosing schedule may reduce chances of side effects. If the 0.5 mg dose is not proving as effective as we hoped, the option then exists to increase to 1 mg daily in 6 months.

Criteria 5: The individual plans to use the medication lifelong.

Every non surgical treatment for androgenetic alopecia is intended to be used life long. This includes minoxidil, finasteride, laser, PRP, dutasteride and others. No patient should ideally start finasteride with the plan to use it short term. There are some exception to this rule of course but the intention for most should be to use life long.