Finasteride and Minoxidil:  Playing a Piano with Two Hands

Many patients ask me which is better finasteride (Propecia) or minoxidil (Rogaine)?  Or, do I have to take both if I am already on one of them?

The answer to the first question is that I personally believe that 70% of the results from medical management comes from finasteride so as a single treatment option I believe that it is far superior to minoxidil.  However, the answer to the second question is that the two medications together work synergistically for a much better result than can be offered with either one alone.  I like to use the analogy of playing a piano with two hands versus playing it with one hand only.

Studies have shown that men who use both medications for many years then decide to stop using one of them lose part of their result.  Conversely, men who are on one product for quite some time then add the second one notice an improvement.  For both of these cases, the reason for the change is that finasteride and minoxidil work on hair loss through two different mechanisms of action and thereby each separately work to improve the situation and together work even more effectively.  Therefore, if it is within your budget and desires to do so, consider taking both finasteride and minoxidil for optimal gains against your hair loss.

Samuel M. Lam, MD, FACS, a board certified hair transplant surgeon in Dallas, Texas. To schedule a hair transplant consultation please call 1-888-866-3388, or visit www.HairTX.com for more info. To ask Dr Lam a question please visit our hair loss product forum.

Hair Loss After Pregnancy: When and Why

I have encountered many patients who experience hair loss after pregnancy and wonder what is going on.  What happens during pregnancy is that the body is sustained at a high level of estrogen.  Estrogen causes the hairs to stay in a prolonged state of anagen, or growth phase.  When the estrogen is reduced at the time of delivery, the hairs cycle back toward a more normal distribution in each of the three hair phases:  anagen, catagen, and telogen.  This condition of related hair loss is known as telogen effluvium.  At the time of childbirth, the hairs appear to shed because the percentage of hairs that were intended to be in a different hair phase rapidly cycle into that phase and hairs are then shed all at once rather than in smaller waves as they do in non-pregnant individuals.

Typically, this hair loss does not make anyone bald, but noticeable thinning can occur.  It is also a self-limiting problem that tends to rectify itself in the first few months after childbirth.  It is oftentimes worse after the first child is delivered than in subsequent pregnancies.  Minoxidil, or Rogaine, can be used to help stabilize the hair loss and shorten the period of shedding.  However, two words of caution should be extended.  Sometimes additional shedding can be noted at 3 to 4 weeks after starting minoxidil because the hairs can cycle back into the growth phase again causing hairs that move into this phase to be shed.  In addition, after stopping minoxidil, hair shedding can be noted again as hairs cycle out of the growth phase. Sometimes not intervening and just waiting it out may be a preferred course of action if there is not significant and socially embarrassing hair loss related to post-pregnancy shedding.  Remember whenever you experience hair shedding it is oftentimes worth seeing a dermatologist on internist just to make sure that it is in fact a benign condition like telogen effluvium and not indicating something more serious.

Samuel M. Lam, MD, FACS is a board certified hair transplant surgeon in Dallas, Texas. To learn more about female hair loss, and Dr Lam’s female hair transplant procedures please visit our website www.HairTX.com or call 1-888-866-3388 to schedule a consultation.

What Hair Loss Products Actually Work?

Fortunately, today there are medical solutions to manage male pattern baldness, which if started earlier can afford better results. The Internet is filled with hawkers of miracle cures, but there are only two FDA-approved products, finasteride (marketed as Propecia) and minoxidil (marketed as Rogaine) that have proven efficacy.

First, we must understand how we lose hair in order to understand how these products work effectively to combat hair loss. Male pattern baldness involves the slow but progressive transformation from thick, terminal hairs of youth to baby, short, wispy vellus hairs, and then finally to complete absence of hair. When 50% of hair is lost, noticeable thinning begins to be apparent. Finasteride and Minoxidil both work toward returning vellus hairs back toward thicker, terminal hairs but they cannot work in the absence of discernible hair, i.e., so-called “slick baldness.”

Accordingly, the earlier in the process of hair loss that these medications are started, the more effective they will be to help slow down and reverse to a certain extent the existing hair loss. If started late in the process of hair loss, they are less effective in managing/reversing the hair loss condition.

The mechanism by which minoxidil works is not entirely clear but it is thought to act as a cellular proliferator or to keep hairs in their growth phase (known as anagen) for a longer period of time. Minoxidil, which is over the counter now, is a topical preparation meant to be applied to the scalp twice daily. Anecdotally, it is thought that the half life of minoxidil in the scalp may be close to 20 hours, meaning that even once a day application can be substantially better than not at all. The package insert reads that minoxidil is only indicated for the crown/vertex region. However, this information is outdated and reflects only the original FDA studies performed over a decade ago. Although new FDA trials were not financed, subsequent studies have shown almost the same benefit in all regions of the scalp.

Minoxidil can lead to temporary increased shedding 3 to 4 weeks after starting the product and that must be known in advance to limit fear on the patient’s part. This temporary effluvium correlates with hairs cycling into the growth or anagen phase, which is a good indicator. In addition over 20% of individuals can experience a delayed (less than 72 hours) or immediate allergic skin reaction to minoxidil, which is significantly more common with the generic or brand named liquid version. The foam version that only comes as brand name Rogaine and only in the 5% male strength has virtually eliminated this problem by removing the propylene glycol component. Minoxidil typically starts to show effect rather quickly within 6 weeks to 3 months. As a reminder, hair loss will continue to occur. Minoxidil will simply slow down the hair loss as well as re-thicken some miniaturized vellus hairs.

Finasteride, an oral pill taken once daily at a 1 mg dosage, is prescription only and helps to slow down and reverse some vellus hairs. It is a medication that takes typically 4 to 6 months to start showing benefit and unlike minoxidil is only indicated for men, as it can cause birth defects in women of childbearing age who take it and has shown little benefit in women who are postmenopausal. Of note, there is no negative effect on children for men who take the medication and impregnate a woman. Finasteride is a dihydrotestosterone (DHT) blocker, that inhibits the conversion of testosterone to DHT via the pathway of the 5-alpha reductase enzyme. The presence of DHT in the scalp causes hairs that are sensitized to possible loss of hair to lose that hair. Because DHT receptors are partly located within the blood vessels that reach the hair follicle, topical finasteride has not shown to be of commensurate benefit as oral medication.

The major side effect with finasteride is sexual, including erectile dysfunction, loss of libido, and possible breast tenderness and/or growth. The incidence of this side effect profile is 1% when compared against placebo and only shows statistical significance when all side effects are aggregated. Side effects are reversible with cessation of the medication, and 57% of men who continue to take the medication show a resolution of their side effects. The individual who takes finasteride should also know that the prostate specific antigen (PSA) value is reduced by half and should therefore be doubled during calculation for men who are being screened for prostate cancer. In addition, because finasteride is metabolized by the liver, liver function tests should be undertaken before starting the medicine and should be followed by a physician as directed. The most recent study in 2008 showed that there is a potential 25% reduction in long-term prostate cancer risk for those who take finasteride.

Finasteride and minoxidil work synergistically to combat hair loss even better than if they were taken in isolation. Those who are willing to take both products and who have been guided by a physician for proper understanding of the risks, benefits, and limitations, should consider doing so. However, one major limitation with both products is that if one should in the future decide to stop taking either product, all the hair that was gained or maintained by that product will be quickly lost over a period of several months. This limitation should always be clearly understood.

Understanding the medical nature of hair loss in men is a prerequisite step before entertaining the desire for possible hair restoration surgery.

Samuel M. Lam, MD, FACS is a board certified, hair restoration surgeon specializing in hair transplant procedures for men and women. To learn more about Dr Lam’s hair restoration procedures please visit our website www.HairTX.com or call 1-888-866-3388 to schedule a consultation.

Dr. Sam Lam, hair transplant surgeon, talks about the role of Propecia (finasteride) and Rogaine (minoxidil) for management of hair loss without hair transplant or in combination with surgery. Understanding the risks, benefits, long-term gains, and shortcomings of these medications is an important first step for anyone considering surgical hair restoration with Dr. Lam (or even for those who are not). This lecture was given on October 3, 2009 in San Diego as part of a course for which Dr. Lam was also the course director. The videos have been conveniently divided into Propecia and Rogaine sections:

Understanding Female Hair Loss & Female Hair Transplants

Before female hair loss can be treated effectively with medication and or surgical hair transplantation, a physician must engage in appropriate dialogue with a woman to determine what causes may be accounting for her hair loss so as to safely rectify or improve her condition.

Many starting hair transplant surgeons rush to perform surgical hair restoration without proper front-end evaluation, which ultimately can lead to dissatisfaction and potentially even worsening of the hair loss. Unlike men who exhibit male pattern baldness, female hair loss must be investigated as to the cause to ensure that surgical transplantation will be both safe and effective.

The two major concerns with woman’s hair loss involves dermatological and more commonly hormonal problems that could be causing the loss of hair. Dermatological conditions include simple scalp conditions like temporary telogen effluvium that can follow delivery of a baby after pregnancy or more serious conditions like discoid lupus, etc. Typically, without any obvious skin lesions, etc., the surgeon who is contemplating surgical transplantation for a woman should recommend hormone evaluation to rule out metabolic conditions.

The most typical hormonal causes for female hair loss include a low iron level (which can be worsened owing to menstruation and with ferritin being the most sensitive blood marker for a treatably low iron level), low estrogen levels due to ongoing aging, etc. (which can be even more prevalent after menopause), low thyroid conditions, high androgen levels (the most common androgen in women is dihydroepiandesterone sulfate, or DHEAS), among other types of hormonal imbalances. A basic yet thorough chemistry panel may be a necessary first start before surgery should be contemplated.

Another important early intervention is managing the hair loss with minoxidil (marketed as Rogaine in the U.S. or Regaine in some countries). Minoxidil is a topical medication that is over the counter in the United States and comes in both 2% and 5% strengths. The 2% version is intended for women. However, for women who do not experience secondary facial or body hair growth, the 5% concentration can at times create a faster response than the 2% concentration but after one year the effects are nearly equal for women being treated with 2% and 5% minoxidil. Also, the 5% foam (which only comes as a brand Rogaine and there is no 2% foam) has eliminated the propylene glycol ingredient making the product less irritable on the skin.

A major drawback with minoxidil is that at 3 to 6 weeks patients may experience temporary further shedding, which is normal and indicative that the hair is entering what is known as anagen, or the growth phase of hair. In 3 to 6 months, hair is typically stabilized or reversed, as the investigation for the cause of the problem is discovered. In any case, if a woman is contemplating surgical hair transplant, the use of minoxidil can be very helpful in minimizing postoperative hair shedding following hair transplantation, as women are more susceptible to temporary shedding after surgery. Accordingly, ongoing minoxidil is a good idea for women considering upcoming surgical hair restoration.

Female pattern baldness presents in three distinct patterns. The most common type of hair loss is known as a “Christmas tree” pattern first described by Dr. Elise Olsen, who believes that it is the predominant pattern of hair loss in women. When a woman parts her hair in the middle and looks downward, the shape of a Christmas tree with the apex toward the back of the head is revealed. A second type of hair loss that could be a variant of Olsen’s category has been described by Ludwig, which is a diffuse thinning throughout the scalp and which has classified according to the extent of thinning into Grades 1 through 3. Finally, the third type of hair loss mimics male pattern baldness with the exception that sometimes the hairline is spared. The purported reason for this variant is that women’s higher serum aromatase level can maintain the hairline in some cases despite diffuse hair loss behind the hairline.

First, the hairline is almost the exact opposite than that for a man. The fronto-temporal region is rounded and low versus open and triangular in a man losing hair. Second, the shape of the female hairline toward the center is also radically different with a cowlick that whorls and so-called lateral mounds that are positioned frequently on either side of the central cowlick. The surgeon creating recipient sites for the hair transplant must almost make these sites in an opposite fashion than for a male candidate, angling sites backward and obliquely, whereas for 95% of men this would lead to a bad outcome. Men’s recipient sites that would accommodate the grafts are anterior, straight and low.

Secondly, when working with women, they may have compromised donor hair in the temple region in conditions of diffuse thinning. Surgeons must know how to harvest this hair to maximize yield and minimize the incisional scar. This involves avoiding the affected temple region and circumnavigating areas of loss that would otherwise create problems down the road for the surgically transplanted result.

Thirdly, women have been notoriously difficult patients regarding their satisfaction following hair restoration unlike men. We believe the most common reason for this outcome can be more likely due to the surgeon’s fault on two accounts. First, unrealistic expectations were created for the patient, and poor communication of objectives was initiated. Secondly and just as important, the design to maximize a result requires judicious allocation of the grafts. We typically prefer to use two major patterns that we call an L-shape and a T-shape. For women who part their hair to the side, we use an L-shape with the longer limb of the L following along the part side and the bottom limb of the L across the central forelock and hairline. The T-shape is ideal for women who part their hair in the midline (or who have greatest density loss along the midline) with the long limb of the T being in the middle and the top horizontal limb of the T again being distributed along the frontal hairline and central forelock that in turn falls immediately behind the hairline. Of course, blending in the surrounding areas around these transplanted areas will yield the most natural result that is also targeted to the pattern of hair loss that a woman is suffering.

This primer on female hair loss and hair restoration clearly does not replace the consultation and relationship between a physician and patient but is intended as a general overview for a patient seeking basic information regarding female hair loss and what could be done for initial investigation, management, and/or surgical correction.

Call 1-888-866-3388 or email us to schedule your female hair restoration consultation. The details of female hair replacement (both the limitations and the benefits in your particular situation) will be explained to you during your hair transplant consultation with Dr. Lam and his team.

When a woman is ready to undergo surgical hair restoration by an experienced surgeon, she should review cases of female hair restoration that the surgeon has done because skills and design work for women differ radically than for men.

	Learn More Female Hair Transplant Information Visit our Female Hair Transplant procedure page. Read about female hair loss disorders.

	Photo Galleries Female Hair Transplant Photos View our Female Hair Transplant photo gallery (before and afters).

	Video Galleries Female Hair Transplant Videos Watch Dr. Lam’s virtual consultation on female hair loss and hair restoration. Watch video on hairstyling for women after hair restoration. Watch a video closeup result of a female hairline and central density hair transplant. Watch a video on female hairline lowering. Watch videos on how Dr. Lam uniquely creates recipient sites for women: Video 1 Video 2.