What is Androgenetic Alopecia?
Androgenetic alopecia affects both men and women. The pattern and distribution of hair loss is quite distinct. In about 60-70% of female pattern hair loss, the vertex or mid-frontal area is affected. For men, almost 98% will have bitemporal recession and over 75% will have mid-frontal and vertext hair loss in their eighties.
The hair follicles are shown in several histology studies to have miniaturized. Many individuals may noticed increased hair shedding and hair thinning of slow onset for many years. This may occur in some cases during the adolescent period in males. Th prevalence of hair loss increases with age for females, with about 40% of women affected after menopause.
Dihydrotestosterone (DHT) is the major metabolite of testosterone that is implicated in male pattern hair loss. Finasteride, an inhibitor of Type 2 5 alpha enzyme, decreases DHT levels on the scalp and serum. Clinical studies have shown that finasteride decreases hair loss, increases hair growth and this improved apperance is sustained with maintenance treatment.
Finasteride or Minoxidil Treatment? Which is Better?
So, is oral finasteride better than minoxidil solution? A study of participants with male pattern hair loss were randomly allocated into two groups for 12 months. The first group took oral finasteride 1mg daily, while the second group applied Minoxidil 5% twice a day. This method of study is known as a randomised controlled trial. Such a study reduces biases and is considered a gold standard in the scientific community.
At the end of treatment, the hair density of both groups were evaluated using the modified Norwood-Hamilton scale. In the finasteride 1mg/day group, 80% of the participants were shown to have modest to significant hair growth. As with the Minoxidil 5% group, 52% of the participants showed improvement at the end of 12 months.
Is Finasteride Safe?
Yes, oral finasteride has been extensively studied and found to be a safe treatment for male androgenetic alopecia. The most common side effects (<5%) are difficulty getting an erection, decreased sex drive and reduced semen volume. These sexual side effects have been shown to reduce over time. Most of the sexual side effects (4.4%) occured during the first year and reduced drastically (0.6%) at the 5th year of oral finasteride 1mg. Therefore, this does indicate that there is no increased risk of sexual side effects with long term treatment with oral finasteride.
Other reported side effects include breast pain, breast enlargement, testicular pain, depression and allergic reactions.
It is important to note that finasteride reduces Prostate Specific Antigen (PSA) levels. The PSA test is used to screen for prostate cancer. You must let your doctor know that you are on oral finasteride if you are undergoing such a test.
Is Combination Finasteride and Minoxidil Treatment Better?
Topical Minoxidil treatment has shown to reduce hair loss, and even promote hair growth. The exact mechanism of action is unknown. Topical Minoxidil may work by increasing the potassium channels, increasing growth factors in the dermis and blood flow to the hair follicles. Most individuals tolerate topical minoxidil well. Side effects such as scalp itchiness, irritation and dandruff may occur in some cases.
For very motivated individuals, one study has shown an increase in hair weight with combination finasteride and minoxidil treatment. It is possible that through different pathways, these 2 drugs may synergise hair regrowth potential.
What About Topical Finasteride and Minoxidil Treament?
The idea of combining topical finasteride and minoxidil treatment together is attractive. It is convenient to use and reassuring for men who are worried about the side effects of oral finasteride.
One study compared the efficacy of topical Finasteride and Minoxidil (combination) vs. Minoxidil (monotherapy). At the end of 24 weeks, the combined treatment group showed a greater improvement (65% vs 25%) compared to using topical minoxidil alone! In this study, the participants tolerated the combined topical finasteride and minoxidil treatment well. There was no reported sexual side effects such as loss of libido and erectile dysfunction.
Dutasteride Treatment For Hair Loss?
The main contributing factor to male pattern hair loss is Dihydrotestosterone (DHT). Circulating testosterone is converted into DHT by the enzyme 5 alpha-reductase (there are 2 types). Finasteride works by inhibiting Type 1 5 alpha-reductase enzyme, while Dutasteride works by inhibiting both Type 1 and Type 2 5 alpha-reductase enzymes. Compared to finasteride, Dusteride is 3 times and 100 times more potent at blocking Type 2 and Type 1 5 alpha-reductase enzymes respectively.
Dustasteride is an established treatment for benign prostatic hyperplasia (BPH). In some studies, it has shown to improve male pattern hair loss by its similar mechanism of action to finasteride. When compared to finasteride, studies have shown Dutasteride 0.5mg/day to be more effective at improving hair growth with no increase in side effects. Dutasteride is considered an off-label use for androgenetic alopecia. A discussion with your doctor is necessary before starting any off-label medical treatments.
How Much Does Oral Finasteride Cost?
One box of PROPECIA® (Finasteride 1mg, MSD) costs from $85-95 for a box of 28 tablets in Singapore. However, there are HSA approved versions of Finasteride 1mg available. One box (28 tablets) Finasteride 1mg daily is only at $64.9 at APAX Medical & Aesthetic Clinics.
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- H. C. Eun, O. S. Kwon, J. H. Yeon et al., “Efficacy, safety, and tolerability of dutasteride 0.5 mg once daily in male patients with male pattern hair loss: a randomized, double-blind, placebo-controlled, phase III study,” Journal of the American Academy of Dermatology, vol. 63, no. 2, pp. 252–258, 2010.
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- Zhou, Z., Song, S., Gao, Z., Wu, J., Ma, J., & Cui, Y. (2019). The efficacy and safety of dutasteride compared with finasteride in treating men with androgenetic alopecia: a systematic review and meta-analysis. Clinical interventions in aging, 14, 399-406. doi:10.2147/CIA.S192435