Today, there are a bewildering number of medical options for hair loss. Many dietary supplements that are designed for healthy hair and that contain biotin can improve hair quality, help with telogen effluvium, but cannot prevent progression of the genetically programmed female-pattern baldness. Unfortunately, many of the herbal and vitamin hair-loss therapies lack substantiated clinical evidence of benefit. With the advent of the internet, numerous sites claim to have the product that can achieve instant hair growth and an enduring fix for baldness. Nevertheless, the Food and Drug Administration (FDA) has approved only two medical therapies for hair loss that have proven to be beneficial in selected patients, oral finasteride (marketed as Propecia by Merck) and topical minoxidil (marketed as Rogaine by Pfizer, now owned by Johnson and Johnson). Finasteride and minoxidil are approved for male hair loss, whereas only minoxidil is approved for female hair loss. Although these products may not be suitable for every person, they do provide a method to reduce or delay further hair loss and in some persons restore some hair fullness. In addition, these medications can also help to optimize the results of surgical hair restoration.

The effects of minoxidil on hair growth were discovered on the sidelines of another treatment. Originally used as a medication to treat severe hypertension, individuals who received minoxidil observed hair growth not only on their scalp but also on their body. Further investigation was conducted aiming to localize the hair-growing effects of minoxidil to the scalp only, leading to the development of the topical solution. Although the initial early reports of oral minoxidil for hypertension linked minoxidil to increasing the risk in heart-disease patients, localized topical minoxidil for hair loss is safe and is an over-the-counter treatment in the United States.

Minoxidil is currently manufactured as a 5% and 2% concentration topical solution intended for direct application to the scalp (not the hair). The 5% concentration is designed for male patients, whereas the 2% concentration is designated for women. However, women who desire a more vigorous treatment can take the 5% concentration, as it has also been recently approved for use in women as a once daily regimen. Interestingly, although the 5% concentration in women can show an increased rate of hair growth early on, there is no statistically significant difference in results between the 5% and 2% concentration after 1 year of usage.

The mechanism of action for topical minoxidil is unclear. As a potassium-channel agonist, the cellular effects on hair growth are only speculative.

However, it is known that minoxidil can cycle hairs out of telogen (the resting phase of the hair cycle) and push them into the anagen growth phase and also lead to a more sustained anagen period. Consequently, many individuals will experience increased hair shedding early on in the treatment for several weeks and should be advised that this phenomenon actually indicates a positive effect of the treatment, as hairs move from telogen to anagen. Considering the length of each hair growth cycle, it takes approximately 6 months for new hair to regrow long enough in order for the person to realize the effectiveness of the treatment. Also, because of this effect that minoxidil has on migrating hairs from telogen to anagen, minoxidil is a recommended treatment for individuals who suffer from acute or chronic telogen effluvium.

The main side effect of minoxidil is an allergic contact dermatitis, which causes a flaky and itchy scalp and accounts for one of the two major objections for use of minoxidil. Another side effect can be heart palpitations and/or increased growth of facial hair (seen mostly in women). The most common brand name for minoxidil is Rogaine. Minoxidil is available in generic form and can be purchased in most pharmacies throughout the world.

Besides side effects, another major reason for the lack of compliance to the product is the complaint about minoxidil making one's hair look oily. Not only does oily hair lack neatness but also it is difficult to style and stick together, further exposing thin areas. Interestingly, some individuals will complain to the contrary, wherein the product renders their hair looking and feeling dry and in some situations leaves behind an unattractive white film. These complaints were mostly resolved with the release of minoxidil foam.

The original minoxidil formula found in the lotion contains the alcohol-based ingredient propylene glycol, the culprit for scalp irritation and oily-looking hair, which when removed from minoxidil foam made the product both water-soluble and more tolerable. The correct application of the product is twice a day. However, once-a-day application may be beneficial considering that the product has been thought to last for 22 hours in the scalp when applied topically as compared with a 4-hour half-life in the bloodstream when used as an intravenous preparation for hypertension.

The hair-growing effects of finasteride were also discovered accidentally when the finasteride 5-mg pill (marketed as Proscar by Merck) was given to patients to manage an enlarged prostate. Subsequent studies found that a 1-mg dosage, which is marketed as Propecia, was adequate to combat alopecia. Finasteride is a prescription-only medication and it works as a type II 5-α reductase inhibitor, where 5-α reductase is the enzyme responsible for converting T to DHT. The presence of circulating DHT impacts hair follicles susceptible to hair loss, and accordingly a lower level of serum DHT can slow progression of hair loss and reconvert vellus hairs back into terminal hairs. The type II 5-α reductase is found predominantly in the hair follicles (and the prostate); and, therefore, it does not promote hair growth anywhere else on the body.

Side effects occur in <2% of the patients and include decreased libido, erectile dysfunction, decreased ejaculate volume, and breast engorgement and tenderness. Side effects should fade away within 6 months after cessation and are found to be resolved in 58% of individuals who continue the treatment. Finasteride is known to reduce serum prostate-specific antigen (PSA) levels by 30–50%. Therefore, individuals over 40 years of age who are taking finasteride should be informed about their altered PSA value and are advised to make certain that their primary- care physician is consulted. Finasteride has been shown to cause potential anatomical abnormalities (hypospadias) in a male fetus in women of childbearing age who take it but not in men who father children and who are on the medication. Therefore, finasteride is absolutely contraindicated in premenopausal women and has shown only equivocal benefit in those who are postmenopausal. In several controlled studies in postmenopausal women, finasteride was shown to have no benefit,1,2 whereas one more recent uncontrolled study indicated that there might be some gain in postmenopausal women who take finasteride.3 Recently, however, a study from South Korea showed that 70 of 86 (81.4%) normoandrogenic women had global photographic improvement with a 5-mg dose of finasteride daily.4 Further, the medical literature may support the treatment with 2.5–5 mg daily dosage of finasteride for postmenopausal women who are obviously not at risk of passing on the potential fetal teratogenic effects.5,6Although finasteride does not cause abnormalities in the fetus when men ingest it, decreased sperm count and semen volume, which may rarely occur, can diminish their fertility. Therefore, men who have difficulties conceiving may consider stopping finasteride during attempts at conception. Trials conducted in 2005 in the field of prostate-cancer prevention initially concluded that the use of finasteride increased the prevalence of prostate cancer. Additional trials conducted in 2008 rectified the original finding: since finasteride shrinks the prostate, it does not cause prostate cancer but facilitates earlier detection of cancer. Finasteride was once banned in sports because of its potential as a steroid-masking agent but recently has been approved for use in the Olympics, the Fédération Internationale de Football Association (FIFA), and many other sports.

Another medication used to treat enlarged prostate is dutasteride (Avodart by Glaxo Smith Kline), which is a potent inhibitor of both Type I and Type II isoenzymes of 5-α reductase. This medication is not FDA-approved for hair loss, and its use is considered experiential and off-label. Of note, a Phase III trial was undertaken in Korea in which 150 men with male-pattern baldness were evaluated over 6-month time and found statistically significant improvement compared with placebo with similar adverse events for all treatment groups.7 More recently, a randomized, double-blind, placebo, parallel 6-month study of 917 subjects involving 39 centers in 9 countries showed dutasteride at 0.5 mg daily had significantly increased hair count in an observed 2.54 cm diameter at week 24 compared with finasteride and placebo. Like the Korean study, adverse events were similar across all treatment arms.8

Initial FDA trials in the late 1990s focused almost entirely on the benefits that finasteride and minoxidil have on the vertex, also referred to as the crown, region.9 However, subsequent studies have shown both medications to be proven beneficial in the frontal, temporal, and midscalp hair. Therefore, individuals who claim that finasteride and minoxidil are only intended for restoration of the crown region are referencing outdated information.i Unfortunately, all the benefits from using these products would fade away with cessation of the medication. As it takes approximately 6 months to develop a visible effect from the medication, it usually requires about the same time for hair to reverse to its starting point once the individual stops medical treatment. Taking both medications has shown to have a synergistic benefit for the individual. When an individual decides to stop one medication, the benefits gained from the single product will disappear, but the improvement attained from the other product will be maintained for as long as the individual continues on with that product.

Although finasteride and minoxidil can provide wonderful results, they are not a replacement for hair transplantation. As standalone treatments, finasteride and minoxidil can convert many wispy vellus hairs back into thicker terminal hairs (but not universally or uniformly so). However, for those individuals who have lost all of their hairs including vellus hairs (so-called slick baldness), neither finasteride nor minoxidil will prove to be beneficial. Nevertheless, even in relatively advanced stages of hair loss, finasteride and minoxidil may retard further hair loss even if no hair is actually restored in the regions of slick baldness. There are three observable effects of medical treatment: preserving the status quo (hair is maintained and the progression of hair loss diminished); increasing hair volume (fine vellus hairs are reverted into thicker terminal hairs, which in turn provides better coverage and better styling options); and increasing hair count (with fewer hairs going into telogen stage, there are fewer hairs falling out and more hairs that remain in the anagen stage).

As established, finasteride and minoxidil do not entirely restore a full head of hair, but they can contribute to a better aesthetic result when combined with hair transplant. Initially, they can help immediately after the surgery to protect original hair from going into postoperative shock and shedding and possibly to accelerate regrowth of the transplanted hair.

Finasteride can be taken without interruption, while it is recommended to stop minoxidil 2–7 days before and after the procedure. Ongoing use of the products is, of course, beneficial and recommended. Whether medications actually cause an increase in hair volume by the conversion of vellus hair into terminal hair or by regrowing or maintaining vellus hair, which would serve to camouflage the scalp, these products can undoubtedly enhance any hair-transplant result. Besides creating a better visual result, medical management will also help retard further hair loss and lengthen the time interval necessary for the next hair-transplant session.

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