There are only 2 FDA approved hair loss prevention medications Finastride (oral preparation) and Minoxidil (Local application). They prevent hair loss and protect existing hairs. They do not grow new hairs where the roots are dead. For more on medications check our blog.

Mechanism of Action

Finasteride 1mg slows the progress of hair loss and increased hair growth in AGA.

It blocks the action of the enzyme type 2 5α-reductase and thereby reduces conversion of testosterone into dihydro-testosterone (DHT).This in turn  reduces DHT level in the scalp by 40- 60%.

• When finasteride is stopped, its action on DHT still lasts up to 2 weeks.
• Applying finasteride over scalp fails to grow hair. It must be taken by mouth.

Dosage
1mg and 5mg showed similar result, so the recommended dosage is 1mg daily. 5mg may have more side effects.

Efficacy
A 5-year finasteride study in men:

• 90% treated had not lost hair
• 65% had increases in hair count.
• The peak increase in scalp coverage was seen at 2 years.
• when pictures were taken, 48% of the treated group showed visual improvement compared to 6% in the placebo group.
• Finasteride could not return vellus hair to terminal hair.
• Effect is only possible for thick hair > 0.04mm diameter.

Uses & Recommendations
In Men
In 1997 the FDA approved a 1mg dose of finasteride for the treatment of AGA. It is important to counsel patients about appropriate expectations and the need for continued therapy. Reversing miniaturization is a slow process. Should take continuously for at least a year before evaluating efficacy. The American Hair Loss Association recommends finasteride as the first line for all men with AGA.

In Women
Finasteride fails to prevent progress of hair loss in female pattern hair loss when the blood level of androgen is normal.

Side Effects
A very safe drug. The only adverse effects reported were decreased sex drive and erectile dysfunction. Incidence was about 1.6% in every 200 treated cases. This is mainly a functional or problem of feeling and not an organic problem of sex organ and which could be experienced even when person is not well, under stress or tired. More over this is reversible on stopping of medication. Painful or swollen breasts (Gynaecomastia) had been reported but very rare. The amount of the active drug in semen is negligible. No evidence that exposure to pregnant women through semen is a risk to human fetus. There fore even use by male during pregnancy and otherwise is safe.

Warnings

• Patients should not donate blood while taking finasteride.
• Yearly PSA level is recommended in appropriate group esp. in elderly.
• The drug should NEVER be taken or even tablet should not be handled by female of child-bearing age. Don't ever ask your wife or girlfriend to cut the tablets. Accidental ingestion by pregnant women may harm the fetus.

Brand name: Propecia, Finax, Finpecia, Fintross etc.

Would Stopping Finasteride cause rapid hair loss?
Hair loss resumes on stopping Finasteride. The loss is gradual and takes many months to be noticed. Eventually you still retain more hair than those not been taking Finasteride.

Should I stop Finasteride as I am planning to have baby?
There are no known harmful effects of Finasteride on fathering a child when used as directed by your physician. The amount of Finasteride in sperm and semen were not significant. Ceasing treatment is not necessary.
Is Finasteride less effective in growing hair in front than in crown area?
Yes, it is less effective in the frontal hairline and temple areas. Finasteride is most effective in stabilizing hair loss or even growing new hair in the crown / vertex area.

(Liquid or Foam preparation, 2%, 5%, !0% Plain or in combination with Retino-A, Amenexil, Azilic acid etc.)

Mechanism of Action
Exact mechanism of hair growth stimulation remains unknown. The Vasodilating action of Minoxidil in increasing local blood supply does not pay a role. Recent studies suggest that Minoxidil may have 2 actions:

• Opens and stimulate a ATP dependent-potassium channels in human hair follicles
• Up regulates the vascular endothelial growth factor (VEGF) and prostaglandin endoperoxide synthase-I, which are involved in hair growth

Efficacy
Minoxidil causes reversible hair growth when used for 4 weeks. Price’s 1999 study over 96 weeks in men showed the followings:

• An increase in hair weight for those treated with minoxidil. The controlled group without using minoxidil continued to lose hair
• Once treatment is stopped hair weight will be lost to the extent as if they had never been treated at all
• A "saturation effect" with minoxidil - strength higher than 5% unlikely to have any addition effect

Dosage

• Applied twice daily
• 5% topical minoxidil is better than 2%:

In Men

• 45% more visible hair growth
• Earlier hair growth
• Increase in hair diameter

In Women

• A significant increase in terminal hair counts in the 5% group
• Patients in the 5% group rated better in results

Critical Rescue Hair Size
Dr. Van Neste showed that over a 2 year period:

• Minoxidil could not return vellus hair to terminal hair
• Effect is only possible for thick hair > 0.04mm diameter

Uses & Recommendations

As for the Minoxidil with Retin-A 1ml is the dose.The best time is in the morning after bath on dry scalp. so that the effect lasts for 24 hours till the next hair wash. Do not apply on hair from the top but use it on the skin. Look skywards and allow drops to fall on the hair line area in the front the liquid will roll over to the back on the skin till the crown rather than hair. That way your hairs may not remain sticky. One of my patients taught me this.

• May take up to 4 months to see any effect
• May have a temporary increased shedding of hair about 3 to 5 weeks after the start of treatment. The hair shed is part of the natural cycle and is normal
• Ideally used for a year before assessing efficacy
• Minoxidil has no effect on the underlying hormonal cause in androgenetic alopecia.
• Once the drug is stopped, hair loss will resume. It's positive effects are at best temporary and long-term results are somewhat disappointing
• The American Hair Loss Association does not recommend minoxidil as the first line for men with AGA. Used when patient is not responding favorably to finasteride, or would prefer combined therapy.

Safety
Minoxidil topical solution is safe. Absorption through skin is low. In combination with Retino-A it has increased skin penetration and should be used only once a day to avoid irritation. The benefit of combination is once a day use and therefore there is higher patient compliance.

Side Effect

• Palpitation or headache esp. in patients taking antihypertensive
• 1 in 20 users will develop skin irritation, a higher incidence with the 5% solution rather than the 2%. This is most likely due to propylene glycol and is less seen in the Foam Preparation that does not have PG.
• Increase of facial hair is mainly seen in women. This effect lessens or even disappears after a year of continued use. It is reversible and goes away 1 to 6 months after the drug is discontinued.
• After hair transplant one should start using after the wound are well healed. Before hair transplant it is stopped for a week to reduce oozing during procedure.

Brand Names: Rogain, Mintop ,Tugain, Combinations: Minokem, Hairmax Fore , Hair4U etc.

Ketoconazole Shampoo 2%
There are so many of shampoo on the market claiming to restore hair, there is only one that was reported to work according to several research studies.

Ketoconazole is an antifungal medication initially used to prevent and treat skin and fungal infections. When applied to the scalp it was shown to suppress the production of androgen in the skin. Recent studies claimed that Ketoconazole shampoo helps to reverse or slow down the process of hair loss by:

• Increase hair density
• Increase the size and proportion of anagen hair follicles.

Mechanism of Action
Ketoconazole acts as a relatively mild anti-androgen by inhibiting DHT production in hair follicles and also by inhibiting binding of DHT to androgen receptors. It is claimed that the anti-inflammatory and anti-fungal properties of Ketoconazole account for its beneficial effect in AGA. A study in mice indicated that ketoconazole may have a direct stimulatory effect on hair growth.

Indication of Use
It is beneficial for AGA patients who cannot tolerate minoxidil because of scalp irritation or contact dermatitis. Used together, Ketoconazole may enhance the effectiveness of other hair loss treatments such as minoxidil and propecia.

Dosage and Frequency of Use
Oral Ketoconazole is not advised as the high concentrations required to affect androgen production exceeds the safety limit. In AGA the only tissue that requires a high concentration of Ketoconazole is the hair follicles. A local application in the form of a shampoo is the best way to delivered Ketoconazole to the affected area. Please note that this shampoo is not used as an cleansing agent, but as a scalp treatment.

For Dandruff Only
Optimal usage is every third day (2 to 3 times a week), leaving the shampoo on the scalp for 3–5 minutes before rinsing. More frequent use is unnecessary but continuous use is required to maintain the benefit. Other shampoo can be used on the other days of the week.

For AGA
3 times a week for 4 weeks. Repeated only as required.

Possible Side Effects
When first begin treatment with Ketoconazole, it is possible to have more shedding of hair. Don't worry as shedding often indicates better response to treatment and better result.