Minoxidil (aka Rogaine/Regaine)
Minoxidil was initially developed in tablet form in the 1970’s to treat high blood pressure. One of the incidental side-effects noted was that of hair-growth. While the oral medication can reverse male pattern hair-loss it can also consequently cause a drop in blood pressure. Minoxidil lotion was then developed specifically for the treatment of hair-loss as a topically applied solution to the scalp. In this way it reduces and minimises the potential side-effects compared to the oral tablet. This occurs as less of the minoxidil is absorbed into general circulation. Topical minoxidil has undergone many clinical trials which show that it is effective in 90 per cent of patients if used over a 12 month period. [ref 1]
Topical Minoxidil comes in a variety of concentrations (2% or 5%) and formulations (lotion or foam). The formulation has no particular effects with regard to the benefits of hair growth. But the different formulations do offer the patient the benefit of choice. Some patients prefer one over the other; the lotion may make the hair appear greasy and in others cause irritation from chemical carriers in the lotion. The foam preparation does not contain the same carriers and is therefore less likely to cause scalp irritation.
The higher the concentration of minoxidil the more effective it is with regard to hair growth. In one of the earlier clinical trials the investigators examined three groups; 5% minoxidil versus 2% minoxidil versus placebo. In this trial there was 45% more hair growth in the 5% group compared to the 2% group. [ref 3]
There are some rare side-effects from Minoxidil. Hair growth has been known to occur in unwanted places such as the face and hands. This is rare and potentially more of an issue for our female patients. Many women are more concerned about their thinning scalp hair than minor facial hair which can readily be addressed by beautician treatments. Any unwanted hair growth is temporary and will stop after cessation of treatment. [ref 4]
Skin irritation is another possible side-effect from the use of Minoxidil. It can cause local skin reactions in the form of irritation, itching (4% of patients) and dermatitis (2% of patients). In the majority of cases the skin irritation is not due to the use of Minoxidil itself, but appears to be secondary to the carrier solution, usually propylene glycol. Patients who develop irritation to the topical Minoxidil solution may thus benefit from the use of topical Minoxidil foam instead. [ref 5]
Finasteride / Propecia
We indicated earlier that one of the by-products of the testosterone metabolism is, dihydrotestosterone (DHT) and that it is implicated in the evolution of male pattern hair loss in the genetically susceptible patient. The medication Finasteride (Propecia) is known to reduce the conversion of testosterone to DHT. Numerous randomised controlled trials have demonstrated the benefit of Finasteride to enhance hair-growth in male pattern hair-loss. Clinical trial evidence has demonstrated that hair growth for 90% of patients stayed above baseline starting level even at 5 years post-treatment. Conversely, in the group that took the placebo treatment , they continued to show hair-loss with volume of hair dropping below their starting level of hair.
Like all medications potential side-effects can occur from Finasteride use. In higher dose (5mg) Finasteride was originally developed (and continues to be used) to reduce the problems of an enlarged prostate in the ageing male population. Thus when used at a lower dosage for hair-growth (1mg) it will somewhat reduce prostate size.
With reduction in prostate size there is a corresponding reduction in semen volume. This, in itself, appears not have any functional consequence. While there may be a reduction in semen volume by approximately 30% this is of no clinical significance. Sperm concentration and hence fertility is unaffected. [ref 6]
There is no increased risk of prostate cancer and, in fact one study found a 24.8% reduction in the risk of prostate cancer in those men taking Finasteride (5mg) per day. Finasteride will lower the level of blood markers used for screening for prostate cancer (prostate specific antigen PSA) and therefore decreases the utility of PSA for prostate cancer screening. [ref 7] [ref 8] [ref 9] [ref 10] [ref 11]
Finally a number of scientific publications suggest a potentially small increased risk of adverse sexual side-effects e.g. reduced libido erectile dysfunction and possibly depression. The robustness of all the evidence is unclear and on balance if there is a risk of the latter this appears to be very small, (<5%) but not zero. It is thus up to each patient to make your own decision about their individual risks and priorities for a non life-threatening condition such as hair-loss and Mr Fogarty at consultation can provide information and advice in this regard.
- J Am Acad Dermatol. 1987 Mar;16(3 Pt 2):677-85.
Safety and efficacy of topical minoxidil in the management of androgenetic alopecia.
Rietschel RL, Duncan SH
- J Am Acad Dermatol. 1999 Nov;41(5 Pt 1):717-21.
Changes in hair weight and hair count in men with androgenetic alopecia, after application of 5% and 2% topical minoxidil, placebo, or no treatment.
Price VH1, Menefee E, Strauss PC
- J Am Acad Dermatol. 2007 Nov;57(5):767-74. Epub 2007 Aug 29. A multicenter, randomized, placebo-controlled, double-blind clinical trial of a novel formulation of 5% minoxidil topical foam versus placebo in the treatment of androgenetic alopecia in men.
- J Eur Acad Dermatol Venereol. 2003 May;17(3):271-5. Hypertrichosis in females applying minoxidil topical solution and in normal controls.
- J Am Acad Dermatol. 2002 Feb;46(2):309-12. Allergic contact dermatitis to topical minoxidil solution: etiology and treatment.
- J Urol. 1999 Oct;162(4):1295-300. Chronic treatment with finasteride daily does not affect spermatogenesis or semen production in young men.
- Efficacy of finasteride 15% increase in hair growth at 2y. J Am Acad Dermatol. 1998 Oct;39(4 Pt 1):578-89.
Finasteride in the treatment of men with androgenetic alopecia. Finasteride Male Pattern Hair Loss Study Group.
- Efficacy on frontal hair loss. J Am Acad Dermatol. 1999 Jun;40(6 Pt 1):930-7.
Finasteride in the treatment of men with frontal male pattern hair loss.
Leyden J1, Dunlap F, Miller B, Winters P, Lebwohl M, Hecker D, Kraus S, Baldwin H, Shalita A, Draelos Z, Markou M, Thiboutot D, Rapaport M, Kang S, Kelly T, Pariser D, Webster G, Hordinsky M, Rietschel R, Katz HI, Terranella L, Best S, Round E, Waldstreicher J.
- Dose ranging 1mg = 5mg. J Am Acad Dermatol. 1999 Oct;41(4):555-63.
Clinical dose ranging studies with finasteride, a type 2 5alpha-reductase inhibitor, in men with male pattern hair loss.
Roberts JL1, Fiedler V, Imperato-McGinley J, Whiting D, Olsen E, Shupack J, Stough D, DeVillez R, Rietschel R, Savin R, Bergfeld W, Swinehart J, Funicella T, Hordinsky M, Lowe N, Katz I, Lucky A, Drake L, Price VH, Weiss D, Whitmore E, Millikan L, Muller S, Gencheff C, et al.
- Increase in hair no(15%).and weight (36%) finasteride 1mg at yr2. J Am Acad Dermatol. 2002 Apr;46(4):517-23.
Changes in hair weight and hair count in men with androgenetic alopecia after treatment with finasteride, 1 mg, daily.
- Persistent Sexual side effects, insufficient evidence. J Clin Aesthet Dermatol. 2014 Dec;7(12):51-5.
Persistent sexual dysfunction and depression in finasteride users for male pattern hair loss: a serious concern or red herring?