Treatment of Male Balding: A closer look at the three tiers of options

Treatment of Male Balding

A variety of treatment options exist for males with balding, also known as androgenetic alopecia. I like to think of the options in terms of three tiers or categories of treatments. Tier 1 treatments have the best evidence and are consistently the most effective. Tier 3 treatments have the least evidence.

Tier 1 Treatments

Minoxidil and Finasteride are the two FDA approved treatments. Dutasteride is off label in North America but is also not uncommonly prescribed as well. These are among the most effective treatments and what I would term "tier 1" treatments. 

Tier 2 Treatments

Other treatments can also be considered including low level laser and platelet rich plasma. Meta-analyses support a benefit of these over placebo or sham treatments so they are not without at least potential benefit. These are what I term "tier 2" treatments. Other tier 2 treatments with less evidence but still reasonable likelihood of benefit include oral minoxidil and topical finasteride. These are not FDA approved and off label.

Tier 3 Treatments

Then we come to "tier 3" treatments. Some treatments in this group might help some males but not all and tesults may be inconsistent. Some tier 3 treatments could be helpful, it's just that not enough studies have been done. The public loves many "tier 3" treatments as they wrongly assume some are completely safe. Many tier 3 treatments simply have not been studied to any significant degree to render conclusions about safety. Lack of studies does not equate to them being safe.

This tier 3 group includes a variety of treatments purported to have a DHT blocking and anti-androgen type effect. There is biochemical evidence of this effect for some of the treatments and even a hint of clinical benefit for others. There is far less study of this group of agents which includes saw palmetto, pumpkin seed oil, ketoconazole shampoo, topical androgen receptor blockers. In the last category are many agents that can be bought on the internet and that I see in my office at least once per week. The evidence for a clinical benefit from these agents is weak at best.

This summarizes the three tiers of non surgical treatments that can be considered in males with balding. A number of exciting options are on the horizon and only careful study will determine if we ever see them in the clinical setting. This includes topical prostaglandin F2 analogues (bimatoprost), prostaglandin D2 inhibitors, Wnt pathway activators, JAK inhibitors and a variety of cell based therapies.