Finasteride 5 mg Tops the List of Effective Treatments for Female Androgenetic Alopecia

5 mg Finasteride May be More Effective Than Topical Minoxidil and 1 mg Oral Minoxidil in Females with AGA

Female pattern hair loss (FPHL), also called female androgenetic alopecia, is a type of hair loss that affects an increasing proportion of women during the aging process.  By age 30, 10%-15% of women may be affected but by age 60 this statistic rises to 40 %. Similar to male androgenetic alopecia (male pattern hair loss), FPHL is associated with the progressive miniaturization of hairs.

 Treatments for FPHL in females include topical minoxidil, oral minoxidil, antiandrogens like finasteride, dutasteride, spironolactone, bicalutamide, laser, PRP and hair transplantation.

 The relative efficacy of various treatments is not clear and even how well some of these treatments even work is not clear.

Gupta et al, 2023

Authors of a new study performed a network meta-analysis (NMA) to estimate the relative efficacy of monotherapy with minoxidil and finasteride of any dosage and administrative route —for adult women with FPHL

To find articles to include in their study, they searched for articles with several characteristics. Articles had to be in the English language and investigated adult women with FPHL, had a group of patients in the study receiving monotherapy with minoxidil or a 5 alpha reductase inhibitor in any dosage/administrative route and reported changes in total hair density at 24 weeks as an outcome measure.

Similar to the authors study in males, inferences regarding a give treatment protocol’s  comparative effectiveness were based on their surface under the cumulative ranking curve (SUCRA) values, and pairwise relative effects

Results

After the authors systematic search, they identified 13 trials whose data were used for the analysis. Data showed that oral finasteride 5 mg was the most effective at 24 weeks followed by 5 % minoxidil solution 1 mL twice daily. The full ranking in the SUCRA analyses are shown here.

Conclusion

I liked this study. It’s a study that really leaves so many more questions open but nevertheless it is valuable. The study shows that finasteride 5 mg should not be downplayed. I spend much of my days responding to the question “Does finasteride really work?” Well, we have a nice summary here. For our naysayers, this study puts finasteride well ahead of topical minoxidil and well ahead of oral minoxidil 1 mg. It’s interesting that twice daily use of 5 % minoxidil solution in women appears so much more effective than once daily 5 % minoxidil solution.

Once must not miss out on a few key points when reviewing this study. This is not a study ranking the treatments for female pattern hair loss. No. This is a study ranking minoxidil and finasteride – and only select minoxidil and finasteride concentrations and doses and only at 24 weeks.

If in theory, one treatment was slower to respond than another, then results may not be fully captured in this 24 week data. In addition, dutasteride data is not here (because good studies are not done) and spironolactone and bicalutamide are not here (because these are not pure 5 alpha reductase inhibitors). That data is important to use as oral spironolactone is among the more common treatments for FPHL in much of the work. In evaluating studies in male balding, oral dutasteride topped the list as the most effective treatment in a similar type analysis by the authors – so clearly we will want to know if dutasteride is more effective than finasteride.

One should note that topical finasteride is not here in this study nor is all our wonderful topical finasteride-minoxidil combinations – the latter of which is something I increasingly use nowadays. Minoxidil foam twice daily is not here either - so we have no idea if minoxidil 5 % foam twice daily might beat out finasteride. What about off label use of minoxidil foam 3/4 cap twice daily? We have no idea - lots of unanswered questions follow this nice study. In addition oral minoxidil at doses 1.25 mg and 2.5 mg are not here – doses which are used in many many many patients.

Data here provides comparisons at 24 weeks. What I would love to see someday is data at 1500 weeks (i.e. 30 years) which is the time that some women will need to use these medications. Right now we have data that is just a fraction (2%) of the length of time we need data. We imagine that these medications just keep chugging along hour after hour and day after day and week after week. The reality is this is a bit of a guess. There is some evidence from data in males that these medications do keep working after 10 or more years quite effectively. But what we need is not guesswork  - but data.

Finally, these data are not a study of side effects. Prescribing medications to patients must take into account the 4 key elements of what I have termed the SAFE principle – safety, affordability, feasibility and effectiveness.  This nice Gupta et al study is largely a study of the last element - effectiveness. Weight gain, mood changes, fluid retention, teratogenicity during pregnancy, heart palpitations, headaches, breast tenderness, decreased libido all impact the day to day of human beings.

This paper will lead to a large number of patients 18-40 demanding to be prescribed finasteride – even moreso than now. Let me say that finasteride is not an appropriate treatment for many, many young women with FPHL. When you actually look at the data you see that SUCRA scores for 5 % minoxidil solution twice daily are just a bit less than 5 mg finasteride. Is it not still reasonable to start with topical minoxidil given all the elements of the safe principle?

In summary, the authors here have examined 13 papers from the medical literature examining the effectiveness of minoxidil and finasteride for treating FPHL. Their results suggest oral finasteride 5 mg tops the list.

REFERENCES

Gupta AK et al. The relative effect of monotherapy with 5-alpha reductase inhibitors and minoxidil for female pattern hair loss: A network meta-analysis study. J Cosmet Dermatol. 2023 Jun 29

Gupta AK et al. Relative Efficacy of Minoxidil and the 5-alpha Reductase Inhibitors in Androgenetic Alopecia Treatment of Male Patients: A Network Meta-analysis. JAMA Dermatol. 2022 Feb 2:e215743.